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Date of admission: 15/07/2023
A 30 year old male, watchman by occupation resident of Suryapet came to casualty with complaints of
Vomiting and losse stools since yesterday morning and SOB since yesterday evening
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 day ago when he when he developed Vomiting (10 episodes) which was non bilious, non projectile and consisting of food particles .
Complaint of loose stools 2 episodes yesterday morning which are watery, non blood tinged,non mucopurulent,not associated with fever, pain abdomen.
Complaint of shortness of breath (grade 3) from yesterday evening which is not associated with chest pain, palpitations, orthopnea, pnd. .
Patient is a known case of Diabetes since 4 years for which he was started on oral medication initially but was shifted to insulin after a occupational accident due to poor wound healing.
Patient also has history of pulmonary TB 4 years ago for which he used ATT for 6 months
Not a K/C/O hypertension, epilepsy, asthma, Thyroid disorders, CKD, CVA
FAMILY HISTORY : Not significant
SURGICAL HISTORY: Not significant
TREATMENT HISTORY: Not significant
PERSONAL HISTORY :
DIET: Mixed
APPETITE:Normal
SLEEP: Adequate
BOWEL AND BLADDER MOVEMNENTS: Normal
ADDICTION: 90 ml whiskey thrice daily
GENERAL EXAMINATION:
Consent was taken prior Examining the patient
No pallor, cyanosis, icterus, clubbing, koilonychia, lymphadenopthy, bilateral pedal edema
VITALS
BP:130/70mmhg
Heart rate :106bpm
Respiratory rate :23cpm
Temperature :98.7°F
SpO2 :98%@RT
GBRS :130mg/dl
SYSTEMIC EXAMINATION
PER ABDOMINAL
Inspection:
No abdominal distension
Scars are present around the umbilicus due to practice of a superstitious belief in his childhood
No sinuses
No engorged veins
No peristalsis seen
Palpation:
No local rise of temperature
No tenderness
Auscultation:
Bowel sounds heard
RESPIRATORY SYSTEM
Inspection:
Bilaterally symmetrical chest movements
No Scars and sinuses present
Trachea central in Position
Accessory nipple on R/S
Percussion:
Bilateral resonant sounds present
Auscultation:
NVBS +
BAE+
CVS
Inspection
Bilateral symmetrical chest movements
No scars or sinuses
Palpation
Inspectory findings are confirmed
Apex beat Normal
Auscultation
S1, S2 heard
No murmurs
No thrills heard
CNS
Higher motor functions intact
Cranial nerves intact
No focal neurological deficits
Provisional diagnosis
Diabetic ketoacidosis with K/C/O Diabetes since 4 years and Pulmonary TB 4 years ago
16/07/2023
INVESTIGATIONS
HEMOGRAM, HBA1C, SERUM CREATININE AND BLOOD UREA, SERUM ELECTROLYTE, LFT
ULTRASOUND
Treatment:
1.IV Fluids 0.4%NS IV @250 ml/hr
2.Inj.Hai 40u in 39 ml NS @ 2.5 ml/hr
3.Inj.5%Dextrose @100 ml/hr according to GRBS
4.Monitor grbs hourly
5.Monitor vitals second hourly
6.strict I/O charting
On 17/7/23
Treatment
1.Inj.nph s/c BD premeal according to GRBS
2.Inj.Hai s/c TID premeal according to GRBS
3.Grbs 7.profile monitoring
4.Monitor vitals fourth hourly
5.strict I/O charting
On 18/07/2023
Treatment
1.Inj.nph s/c BD premeal according to GRBS
2.Inj.Hai s/c TID premeal according to GRBS
3.Grbs 7.profile monitoring
4.Monitor vitals fourth hourly
5.strict I/O charting
Patient was discharged on 18/07/2023
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