65F DKA ; DM Since 20Y

 Case History and Clinical Findings

PATIENT WAS BROUGHT TO THE CASUALITY WITH COMPLAINTS OF PAIN ABDOMEN

AND VOMITINGS SINCE 23-4-23 4PM

HOPI-

PATIENT WAS APPARENTLY NORMAL UNTIL 23-4-23 4PM SINCE THEN SHE DEVELOPED PAIN ABDOMENWHICH IS INSIDIOUS IN ONSET ,GRADUALLY PROGRESSIVE ,SQUEEZING TYPE OF PAIN

ASSOCIATD WITH VOMITINGS WHICH ARE 2 EPISODES ,NON PROJECTILE,MUCOID,WITH FOOD PARTICLES AS CONTENT

H/O NAUSEA PRESENT,SHORTNESS OF BREATH PRESENT GRADE-2

H/O FEVER SINCE 1 DAY HIGH GRADE ,INTERMITTENT,NOT ASSOCIATED WITH CHILLS AND RIGORS,RELIEVED BY MEDICATION

PAST HISTORY-

K/C/O DIABETES MELLITUS T-2 SINCE 20 YRS AN DON MEDICATION[UNKNOWN]

N/K/C/O HTN,TUBERCULOSIS,EPILEPSY,CVA,CAD,THYROID DISORDERS

PERSONAL HISTORY-
DIET: MIXED
APPETTITE:NORMAL
BOWEL AND BLADDER: REGULAR
SLEEP: ADEQUATE
NO ADDICTIONS

GENERAL EXAMINATION-PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE
WELL ORIENTED TO TIME,PLACE,PERSON
MODERATLY BUILT AND NOURISHED

VITALS-
TEMPERATURE-AFEBRILE
PR-88BPM
BP-130/70
RR-18CPM

SYSTEMIC EXAMINATION-
CVS-S1S2 HEARD,NO MURMURS
RS-BAE+,NVBS HEARD
CNS-NFND,HMF INTACT
P/A-SOFT,NON TENDER,NO ORGANOMEGALY

Diagnosis:-
DIABETIC KETOACIDOSIS
K/C/O DIABETES MELLITUS T2 SINCE 20 YRS

Investigation
ECG-NORMAL SINUS RHYTM
ULTRASOUND-NO ABNORMALITY DETECTED
HAEMOGRAM
24/4/23
HB 8.9
TLC 30,500
NEUTROPHILS 89
LYMPHOCYTE 06
PCV 31
MCV 91.4
MCH 26.3
MCHC 28.7
RBC 3.3 MILLION/CUMM
PLT 3.1LAKHS/CUMM

Treatment Given(Enter only Generic Name)
SOFT DIET
IV FLUIDS NS@75ML/HOUR
INJ.PIPTAZ 4.25GM /IV/BD
INJ.PAN 40 MG/IV/OD
INJ.ZOFER 4 MG/IV/SOS
INJ.HAI S/C TID[BEFORE MEALS]
INJ.NPH S/C BD [BEFPRE MEALS]
T.PCM 650MG/PO/TID
GRBS 7POINT PROFILE MONITORING
BP MONITORING 2ND HOURLY
STRICT I/O CHARTING
SYP.ASCORIL-D 2.5ML/PO/TID
SYP.CITRALKA 10ML/PO/TID IN 1 GLASS OF WATER

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