K. Kavyasree (197) 06.03.2022
E-LOG GENERAL MEDICINE
DIABETIC KETOACIDOSIS
06.03.2022
Hi, This is K.Kavyasree a third semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.
A CASE OF DIABETIC KETOACIDOSIS
CHIEF COMPLAINTS:
A 24 year male patient sand contractor by occupation came with chief complaints of
* Loss of appetite and generalised weakness since 1 week
HISTORY OF PRESENT ILLNESS:
* patient was apparently asymptomatic 1 week back then he had generalized weakness associated with loss of appetite and loss of weight(2kg)
.
* There is no associated fever, vomitings, loose stools. Pain abdomen, chest pain, palpitations.
HISTORY OF PAST ILLNESS:
* 2 Weeks back patient have episode of giddiness went to local RMP and found to be having high BP (170/120mm of hg) and gave tablets and injections for 2 days.
Not k/c/o Diabetes, asthma, tuberculosis, epilepsy
No previous surgeries and blood transfusions.
K/c/o hypertension.
PERSONAL HISTORY:
He is unmarried.
Mixed diet.
Appetite :Normal
Micturtion: Normal
Bowel and bladder habits : Normal
No addictions.
FAMILY HISTORY:
Has no family h/o HTN, TB, heart disease,cancers, epilepsy.
Family h/o of DM (father)
GENERAL EXAMINATION :
Vitals :
• BP - 150/70 mmHg
• Temp. - 98.4°
• SpO2 - 98%
• RR - 24 cycles/min
• PR - 84 bpm
•GRBS : 472 mg%
PALLOR : Absent
ICTERUS : Absent
CYANOSIS :Absent
CLUBBING :Absent
GENERALIZED LYMPADENOPATHY :Absent
ODEMA :Absent
SYSTEMIC EXAMINATION :
CVS:
• S1, S2 heard
• No thrills and cardiac murmurs
RESPIRATORY SYSTEM:
• No dyspnoea, wheezing
• Postion of trachea - central
• Breath sounds - Vesicular
ABDOMEN:
• No tenderness, palpable mass, bruits
• No palpable liver and spleen
•Shape :Schapoid
CNS:
• Conscious and coherent
• Speech - normal
• No signs of meningeal irritation
• Glass gow coma scale - 15/15
PROVISIONAL DIAGNOSIS:
• DIABETIC KETOACIDOSIS
TREATMENT:
On 1/3/2022
Rx:
1. 1ml HAI +39ml NS @ 6ml/hr
2.IV NS Continuous infusion@200ml/hr
3.GRBS 1 Hourly
4. Strict I/O charting
2/3/2022
1ml HAI +39ml NS @ 6ml/hr
2.IV NS Continuous infusion@200ml/hr
3.GRBS 1 Hourly
4. Strict I/O charting
3/3/2022
1.Inj HAI 100-100-100
NPH 100-X-100
2.INJ Thiamine 1amp in100 ml NS IV (TID)
3.GRBS before food and 2 hrs after food.
4.Strict I/O charting
4/3/2022
1.Allow soft diet
2.Tab GLIMY-M1PO/BD
3.GRBS before food and 2 hrs after food.
4.INJ Thiamine 1amp in100 ml NS IV (TID)
5.Monitor vitals
6.I/O charting
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