30 YEAR OLD FEMALE WITH UNCONTROLLED SUGARS

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is 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, investigations and come up with diagnosis and treatment plan.

AFEEFA FARZANA ,8th SEMESTER

Roll no:09

A 30 yr old female patient sweeper by occupation brought to casualilty with fever and vomitings and hypersalivation. 

She had low grade, intermittent fever which relieves on medication not associated with chills and rigors.

HOPI: She had 5 episodes of vomitings for 2 days which contained food particles, non projectile and non foul smelling. She needed support for walking.

Fever since 3 days, vomitings 5 episodes(12th & 13th June 2022), unable to walk since 2 days

Negative history: no history of shortness of breath, cough, loose stools

ast illness- known hypertensive since 2 years (using medication)

NOT a known case of DM, asthma, tuberculosis, diabetes, asthma, epilepsy, CAD

Personal History: Mixed diet

Bowel And Bladder-Regular 

 Sleep Adequate 

No Allergies And Addictions.

Family History: not significant 

General Examination: 

Patient is Conscious, 

Moderately Built and Nourished.

Pallor Absent

Icterus Absent

Clubbing Absent

Cyanosis Absent

Lymphadenopathy Absent

Edema Absent 

Vitals : 

Temperature - afebrile 

Pulse:  114/min

B.P: 140/80mmHg

SpO2: 98% on RA

GRBS: high

Systemic examination:

ABDOMEN: Palpable liver, no tenderness, distended abdomen.

Lab diagnosis:

Treatment history:

13/6/22

*IVF NS@100ml 

*Inj Monocef@1 gm x IV x BD

*Inj Human Actrapid (1ml+39ml NS)@6ml/hr

14/6/22

*IVF 20NS@100ml/hr

D-1 *Injection monocef 2gm×IV×BD

*Injection human actrapid insulin

                  1ml +39ml NS @ 6ml/hr

*Injection zofer 4mg IV  BD

*Injection pan 40mg IV BD

*GRBS 1hourly

*Monitor vitals hourly