GENERAL MEDICINE

ch.nagatarun kumar

3rd semester

 21year old male resident of miryalaguda came to casualty with chief complaints of 

fever since 5 days, c/o decreased appetite since 7days, c/o vomiting since 1day, c/o sob since morning.

Patient was apparently asymptomatic 5days back then he developed fever which was insidious in onset, intermittent and was of high grade type a/w chills and relieved on medication. Pt had h/o 1episode of vomiting 1day back which was non-bilious,non- projectile.

No h/o any burning micturition, throat pain, cold,cough.

PAST HISTORY:

Not a k/c/o HTN,DM, CAD, asthma, TB, epilepsy.

PERSONAL HISTORY:

Patient has mixed diet with normal appetite and adequate sleep. 

he has normal bowel movements and bladder filling. 

No addictions. 

No significant family history or allergic history. 

GENERAL EXAMNATION:

Patient is c/c/c ,moderately built and moderately nourished. 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 

VITALS:

BP: 140/90 MMHG, 

PR: 120bpm 

Temp: 98.2°F, 

RR: 40 CPM, 

SPO2: 99% 

RS: BAE+,NVBS heard

CVS: S1 ans S2 heard. No murmurs.No thrills

P/A: soft and non-tender. 

CNS: No focal deformities. 

INVESTIGATIONS:

1) HEMOGRAM : 

Hb: 8.2

TLC: 15800

N:89

L:6

PCV: 30

Mcv:63.7

MCH:17.4

MCHC:27.3

PLC:3.37

RBC:4.71

2) LFT:

3)CUE

4)RBS:194 

5)BLOOD UREA:29

6)SERUM CREATININE:0.8 

7)URINE FOR KETONE BODIES:

8)ABG@2PM 

9)SERUM ELECTROLYTES @2pm

S.ELECTROLYTES@ 10PM 

10) Chest xray PA view: 

PROVISIONAL DIAGNOSIS:DIABETIC KETOACIDOSIS WITH DENOVO DETECTED DIABETES MELLITUS WITH VIRAL PYREXIA UNDER EVALUATION

TREATMENT: 

On DAY-1

1)NBM till further orders

2)IVF 3lit NS @500ml/hr(in 3hrs) f/by IVF NS@250ml/hr 

3)Inj. HAI 4IU IV/stat f/b Inj. HAI 1ml (40IU) in 49ml NS @ 4ml/hr(untill ABG correction)

4)Inj. PAN 40mg IV/OD

5)IVF 5%DEXTROSE @50-100ml/hr(when GRBS <150) [increase/decrease acc. to GRBS]

6)Inj.OPTINEURON 1amp in 100ml NS/IV/OD 

7)GRBS monitoring hourly

8) Strict i/o. Monitoring

9)Inj. KCl 2amp in 500ml NS @100ml/hr

On DAY-2 :

SOAP NOTES:

S: 

No fever spikes,sob decreased ,no fresh complaints

O:

BP-110/90mm hg

PR-74bpm

CVS:S1S2 heard

Rs:BAE +,NVBS

P/A:soft

A:

HAGMA, DKA

Hemogram:

ABG @1AM

@8AM

@3PM

S.ELECTROLYTES:@8AM

@5PM

@10.30PM

P:

1)IVF 0.45% NaCl,RL @100ml/hr 

2)Inj. KCl 2amp in 500ml NS @100ml/hr

3)Inj. HAI 1ml (40IU) in 39ml NS @ 4ml/hr(untill correction of acidosis)

4)Inj. PAN 40mg IV/OD

5)Inj.OPTINEURON 1amp in 100ml NS/IV/OD 

6)GRBS monitoring hourly

7)Strict i/o. Monitoring

8)NBM till further orders

DAY-3 :

S: Patient sob decreased,No fresh complaints

O: BP 110/80 mm hg

PR: 70 bpm

CVS: s1 s2 heard 

RS: BAE+ NVBS 

P/A: soft 

ABG@6.30AM

S.ELECTROLYTES @8AM

Assesmemt : over night patient grbs around 290 mg/dl and Patient anion gap is reducing day by day and subjectively feeling better .

Plan of care : Look for today morning abg and stop iv insulin infusion and start him on NPH and HAI

DAY-4

21yr old Male shifted to AMC

S: no fresh complaints

O: BP130/80 mm hg

PR 80 bpm

CVS: s1 s2 heard 

RS:BAE + NVBS 

P/A: soft,non tender

Assesmemt :  

DKA

GRBS 157mg/dl 

FBS :114 mg/dl

Hemogram:

 

Plan : 

Stopped insulin infusion

Started Inj. NPH S/C according to grbs(8am---2pm---8pm)

Inj.HAI S/C acc to grbs

IVF NS,RL @100ml/hr

INJ.PAN 40mg