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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