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THIS IS A CASE OF 20 YEAR OLD FEMALE PATIENT  WHO WAS BROUGHT TO CASUALTY WITH 

C/O FEVER SINCE YESTERDAY                                C/O ALTERED SENSORIUM SINCE TODAY MORNING

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC TILL YESTERDAY THEN DEVELOPED

FEVER,HIGH GRADE ASOCIATED WITH CHILLS AND RIGOR,NO DIURNAL

VARIATION,RELIEVED WITH MEDICATION.

ALTERED SENSORIUM SINCE TODAY MORNING

NO C/O BURNING MICTURATION /VOMITINGS/LOOSE STOOLS/CHEST PAIN

/PALPITATIONS/ORTHOPNEA/PND

H/O POLYPHAGIA +,POLYDYPSIA +

PAST HISTORY:

N/K/C/O HYPERTENSION,DIABETES,THYROID DISORDERS,EPILEPSY,CVA,CAD

PERSONAL HISTORY

DIET-MIXED

APPETITE-NORMAL

SLEEP-ADEQUATE

BOWEL AND BLADDER MOVEMENTS-REGULAR

ADDICTIONS -NONE

COURSE IN HOSPITAL -

20 YEAR FEMALE WAS BROUGHT TO CASUALTY IN ALTERED SENSORIUM WITH GRBS OF 540MG/DL URINE FOR KETONE BODIES POSITIVE ABG DONE AND PRESENTED WITH DIABETIC KETOACIDOSIS WITH DENOVO DM .INSULIN INFUSION WAS STARED AND TAPPERED ACCORDING TO GRBS .PATIENT HAD COMPLAINTS OF WAXY EAR DISCHARGE ENT REFFERAL WAS TAKEN AND ADVICED FOLLOWED .PATIENT IS PLANNED FOR DISCHARGE AND HEMODYNAMICALLY STABLE STATE AND PLANNED FOR DISCHARGE. ENT REFFERAL WAS DONEAS SHE WAS HAVING COMPLAINTS OF RIGHT EAR PAIN AND RIGHT EAR DISCHARGE. EXMINATION WAS DONE AND MEDICATION WAS GIVEN-

CIPLOX E/D 3D---3D---3D X5 DAYS

OTRIVIN N/D 3D---3D---3D X 5 DAYS

TAB. LEVOCET 5MG OD/HS X 5 DAYS

GENERAL EXAMINATION:

PATIENT IS CONCIOUS , COHERENT , COOPERATIVE , MODERATELY BUILT AND

NOURISHED

NO PALLOR , ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA

VITALS:

TEMPERATURE - AFEBRILE

BP- 110/70 MM HG

PR - 88 BPM

GRBS-540MG/DL

SYSTEMIC EXAMINATIONS:

CVS - S1,S2 + NO MURMURS

R/S - BAE+ NVBS+

P/A - SOFT, NON TENDER

CNS- NFND

Investigation

HEMOGRAM:

HB:- 11.1 GM/DL 10.9

TLC- 16700 CELLS/CUMM 6800

PLATLET COUNT-3.07 LAKHS/CUMM 2.32

SERUM CREATININE:0.8 MG/DL

UREA:30 MG/DL

SODIUM:136 MEQ/L

POTASSIUM: 4.2 MEQ/L

CHLORIDE:109 MEQ/L

SERUM OSMOLALITY:287.8

RBS:308


CUE:

SUGARS- ++

ALBUMIN-+

BILE SALTS AND PIGMENTS-NILL

PUS CELLS-3-4

EPITHELIAL CELLS- 2-3

LFT:

TOTAL BILIRUBIN: 5.33 MG/DL

DIRECT BILIRUBIN :1.22 MG/DL

AST :19 IU/L

ALT: 10 IU/L

ALKALINE PHOSPHATE:240 IU/L

TOTAL PROTEIN:7.1 GM/DL

A/G : 1.11


ABG:

PH-7.13 7.32 7.42 7.44

PCO2-9.7 19.2 19.8 24.4

PO2-67.2 80.9 117 97.6

HCO3-3.1 9.7 12.8 16.6

ST.HCO3-7.3 13.6 16.9 19.9

BEB: - 26.1 -14.4 -9.5 -5.5

O2 SAT- 93.4 96.7 98.1 97.7


SERUM ELECTROLYTES:

NA - 133

K-4.1

CL- 104

URINARY KETONE BODIES- +

LDH-579

COOMBS TEST; -VE

HBA1C-7.0

NA - 137

K-2.9

CL- 104

USG ABDOMEN - NO SONOLOGICAL ABNORMALITIES

Treatment Given

1.INJ MONOCEF 1MG IV/BD

2.IV FLUIDS NS @ 75ML/HR

3.INJ HAI SC PREMEAL/TID

4.INJ NPH SC PREMEAL/BD

5.INJ PAN 40MG IV/BD/BBF

6.INJ ZOFER 4MG IV/SOS

7.INJ PCM 1MG IV/SOS

8.TAB PCM 650MG PO/QID

9.SYP ASCORIL -LS 10ML PO/TID

10.STRICT I/O CHART

11.GRBS 7 PROFILE MONITORING

12.BP,PR,TEMP MONITORING 4TH HOURLY

13.POTASSIUM RICH DIET


Advice at Discharge

1. TAB. TAMIM 200MG PO/BD X 3DAYS

2. INJ. HAI SC PRMEAL TID

14 UNITS-------14 UNITS------14 UNITS.

3.INJ. NPH SC PREMEAL BD

12U-------X-------12U

4.TAB. PAN 40 MG PO/BD BBF X 1WEEK

5.CIPLOX EAR DROPS

3DROPS-----3D----3D X 5D

6. OTIRIVIN N/D

3D-----3D-----3D X 5D

7. STRICT DIABETIC DIET( EXPLAINED )

8. HOUSE GRBS MONITORING.

9.TAB. ZOFER 4MG PO/SOS

10.TAB. PCM 650 MG PO/SOS


Follow Up

REVIEW TO GM OPD WITH FBS, PLBS AFTER 1 WEEK.



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