41yr old female with vomitings and abdominal pain

This is online E log book to discuss out patients de-identified health data shared after taking his / her guardian`s informed consent. Here we discuss our individual patient`s problems through series of inputs from available global online community of experts with an aim to solve patients clinical problems with collective current best evidence based inputs. 

     This E log book also reflects my patient centered online learning portfolio and your valuable inputs on comments box is welcome .

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references




41 year old female housewife hailing from Miriyalguda came to casualty with C/O:
1) Nausea and vomiting since 10 hrs 
2) Abdominal pain since 10 hrs



HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 10 hours ago then she developed nausea and vomiting, 8-10 episodes of vomiting, content food material watery, non bilious, non projectile, not blood binged associated with Abdominal pain of diffuse type and non radiating.

No H/O chest pain, Pedal edema, burning micturition, coughing, palpitations, excessive sweating, giddiness and wheeze

H/o skipping OHAs since 2 days


PAST HISTORY 

K/c/o Diabetes Mellitus type 2 since 2 years for which she is on medication (Tab Glimi M1 )
H/o raised blood pressure.
H/o undergoing tubectomy.
No h/o addiction or allergies



GENERAL EXAMINATION

O/E: 

Patient is concious, coherent and cooperative

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.









Vitals:

BP: 170/110mmhg

PR: 68bpm

RR: 16 cpm

TEMPERATURE: 97.8 F

GRBS: 200 mg/dl

SPO2: 98% at RA


SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM EXAMINATION : 

Bilateral air entry +
Normal vesicular breath sounds heard
Trachea central 
No added sounds 

CVS EXAMINATION : 

S1, S2 heard 
No murmurs 

ABDOMEN EXAMINATION : 

Soft, no tenderness 
No organomegaly
Bowel sounds - present 


CNS EXAMINATION : 

Gcs - E4V5M6 (15/15)
Higher mental functions - normal 
Cranial nerve examination - normal 
Sensory and motor system normal 

No signs of meningeal irritation


 INVESTIGATIONS:

Urine for ketone bodies -positive





ABG

USG ABDOMEN

2D echo

Chest xray:normal

Ecg


PROVISIONAL DIAGNOSIS:
Diabetic ketosis with DM type 2.


TREATMENT:
1)INJ. ZOFER 4mg, IV/TID 

2)INJ. PAN 4Omg, IV/OD 

3)INJ. HAI, SC/TID (according to GRBS)

4)IV fluids NS, 100 ml/ hour

5)Strict GRBS monitoring 
















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