GENERAL MEDICINE E- LOG

 32 CH SRILEKHA

Hello everybody , this is ch srilekha , a third semester student.

This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.

 

A 18 year old male resident of kistapuram, student by occupation came to causality with chief complaints of 

1. Vomitings since 3days.

2. Shortness of breath since 3 days.

3. Chest pain since 3days.

HISTORY OF PRESENT ILLNESS

The patient was apparently asymptomatic 4 days ago . The next after eating in the afternoon he had an episode of vomiting non projectile, non bilious, content food and blood stained. During the night he had 2 more episodes of vomoting , non projectile, non bilious, non blood stained. He also had chest pain and shortness of breath along with vomitings during the night for which he was bought casuality the next day morning. 

HISTORY OF PAST ILLNESS

History  of admission to our hospital in july in view of jaundice .

Had high sugars and HbA1c was 8.5 , and diagnosed with type 1 diabetes mellitus .Taking Mixtard insulin 15U in the morning and 15U in the evening.

PERSONAL HISTORY

Occupation - Student

Diet - Mixed

Apetite - Normal

Bowels - Regular 

Micturition - Normal

He has no known allergies.

TREATMENT HISTORY

No specific treatment history

FAMILY HISTORY

No significant family history

DRUG HISTORY

Taking Mixtard insulin 15U in the morning 15U in the evening  since july 2021.

GENERAL EXAMINATION

Patient is conscious , coherent , cooperative.

VITALS 

Pulse rate : 72bpm

BP : 110/80 mmHg

Respiratory rate : 13cpm

Temperature : Afebrile 

SpO2 : 97% at room air 

GRBS : 400 mg /dl

PHYSICAL EXAMINATION 

Pallor : absent 

Icterus : absent 

Cyanosis : absent

Clubbing of fingers/toes : absent

Lymphadenopathy : absent

Edema : lower limb pitting edema

Malnutrition : absent

Dehydration : absent

SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM

• S1 and S2  heard
• No thrills 
• No cardiac murmurs

RESPIRATORY SYSTEM 

• Dyspnoea - present
• No wheezing 
• Trachea - central
• Vesicular breath sounds heard

ABDOMEN 

Soft, diffuse  abdominal tenderness with more pain in the epigastrium and right hypochondrium.

CNS

• Conscious and normal speech
• No signs of neck stiffness
• Power 5/5 in 4 limbs
• Pupil - NSRL
• Reflexes are all +2

INVESTIGATIONS

 X RAY

ECG 

PROVISIONAL DIAGNOSIS

Diabetic ketoacidosis with k/c/o type 1 diabetes mellitus.

TREATMENT 

1. HAI infusion 40 IU in 40ml infusion at 6ml/hr

2. Inj. CEFTRIOXONE 1gm IV BD 

3. Inj. OPTINEURON 1amp in 100ml NS IV OD

4. IVF NS 100ml/hr

5. Inj. PAN 40mg IV OD

6. Inj. ZOFER 4mg IV TID

7. Temp charting 

8. GRBS charting 

9. BO,PR,RR,SpO2 monitoring