A 58 year old female patient

 This is an online E log book to discuss our patient's 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 available global online community of experts with an aim to solve those patient's clinical problems with 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


Cheif complains

The patient presented to the OPD with the chief complaints of  Vomiting since 8 days, Decreased appetite and fever since 6 days and SOB from 3 days

HOPI

The patient was apparently asymptomatic 8 days back Then she developed vomitings and the contents are The food consumed  prior.she developed decreased appetite six days back.Fever since six days which is intermittent and is relieved on medication.

PAST HISTORY 

k/c/o DM type 2 and HTN since 20 years

VITALS

BP-130/80 mm of hg

PR-87/min

RR-20/min

afebrile

SYSTEMIC EXAMINATION 


CVS:S1S2 heard 

Jvp not raised

No murmurs heard

RESPIRATORY:grade 3 dyspnea

ABDOMEN: Normal


















INVESTIGATIONS 




PROVISIONAL DIAGNOSIS 

uncontrolled type 2 DM

TREATMENT 

-normal soft diabetic diet

-IVF -NS/RL 75 ml

-INJ. HAI  acc to GRBS

-INJ OPTINURON 1 amp

-INJ ZOFER 4mg IV/OD 

-INJ LASIX 20 mg IV/BD

T.MET XL 25 mg PO/OD

Strict GRBS monitoring second hourly




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