28 year old with Diabetic Ketoacidosis
This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome.
I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, and investigations, and come up with a diagnosis and treatment plan.
CASE PRESENTATION:
28 year old female presented with complaints of
Vomiting 6 days back
Burning micturition since 5 days
Shortness of breath since 6 hours
Hopi: patient was apparently asymptomatic 6 days back, then she had vomiting 6-7 episodes of non bilious, non blood stained, non projectile, yellowish to green in color. No h/o diarrhoea
She had burning micturition since 5 days. Not associated with pain abdomen, fever
She had shortness of breath since 6 hours, sudden in onset, gradually progressive
No h/o orthopnea, pedal edema, PND, palpitations, chest pain
Past history:
K/c/o diabetes type 1 since 2 years and is on insulin 15 units s/c BD
N/k/c/o HTN, epilepsy, TB, Asthma
Personal history:
Takes mixed diet, with normal appetite
Has regular bowel and bladder habits
No addictions
O/E: patient is conscious and coherent
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy
Pitting type of pedal edema present upto knee
Vitals
Temp:96.8F
PR:118 bpm
RR:42 cpm
BP:140/90 mm hg
GRBS: 181 mg/dl
CVS: s1 s2 heard
RS: BAE present
P/a: soft, non tender
CNS: NFND
Investigations:
Ph: 6.9, pco2: 5.7, po2: 137, bicarbonate:1.1
Ph:7.1, pco2: 6, po2:134, bicarbonate:1.8
On 27/3
Ph: 7.2, pco2: 22.2, po2: 61.2, bicarbonate: 10.2
Diagnosis:
Diabetic ketoacedosis
DM since 2 years
Treatment: This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome.
I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, and investigations, and come up with a diagnosis and treatment plan.
CASE PRESENTATION:
28 year old female presented with complaints of
Vomiting 6 days back
Burning micturition since 5 days
Shortness of breath since 6 hours
Hopi: patient was apparently asymptomatic 6 days back, then she had vomiting 6-7 episodes of non bilious, non blood stained, non projectile, yellowish to green in color. No h/o diarrhoea
She had burning micturition since 5 days. Not associated with pain abdomen, fever
She had shortness of breath since 6 hours, sudden in onset, gradually progressive
No h/o orthopnea, pedal edema, PND, palpitations, chest pain
Past history:
K/c/o diabetes type 1 since 2 years and is on insulin 15 units s/c BD
N/k/c/o HTN, epilepsy, TB, Asthma
Personal history:
Takes mixed diet, with normal appetite
Has regular bowel and bladder habits
No addictions
O/E: patient is conscious and coherent
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy
Pitting type of pedal edema present upto knee
Vitals
Temp:96.8F
PR:118 bpm
RR:42 cpm
BP:140/90 mm hg
GRBS: 181 mg/dl
CVS: s1 s2 heard
RS: BAE present
P/a: soft, non tender
CNS: NFND
Investigations:
Ph: 6.9, pco2: 5.7, po2: 137, bicarbonate:1.1
Ph:7.1, pco2: 6, po2:134, bicarbonate:1.8
On 27/3
Ph: 7.2, pco2: 22.2, po2: 61.2, bicarbonate: 10.2
Diagnosis:
Diabetic ketoacedosis
DM since 2 years
Treatment:
1. IV FLUIDS NS @100ml/hr
2. INJ HAI S/C TID according to GRBS
3. INJ NPH S/C BD according to GRBS
4. GRBS monitoring hourly
Comments
Post a Comment