A 20 YEAR OLD MALE CAME WITH FEVER AND VOMITING



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 patients 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 comment box is welcome.

A 20 year old male driver came to opd wit complaints of 

1) Fever since 2days 

2) Vomiting since 6hrs

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 2 days back then he developed fever which is not associated with chills and rigors and relieved with medication. No diurnal variation.

Vomiting since 6hrs with 3 episodes and content as food material, blood tinged, non bilious, non projectile.

He skipped 1 dose on insulin yesterday evening.

No h/o loose stools, pain abdomen, giddiness.

No h/o fever, burning micturation.


PAST HISTORY

K/c/o Diabetes mellitus - Type 1 since 2years and is on medication

1) HAI 14-14-14

2) NPH 26U-X-26U

H/o COVID MISC

Not k/c/o HTN, Asthma, CAD, Epilepsy, TB.


PERSONAL HISTORY

Appetite- Normal

Diet- Mixed

Bowel and bladder- Regular

No addictions

No allergies


GENERAL EXAMINATION

No signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, edema.

Vitals

Temp- 96.8 F

BP- 130/70mmhg

RR- 22cpm

PR- 104bpm

GRBS- 311mg/dl


SYSTEMIC EXAMINATION

CVS- S1,S2 HEARD

RS- BAE+, NVBS

P/A- Soft, nontender

CNS- NAD

ABG ON 18/8/23




ABG ON 19/8/23




SERUM ELECTROLYTES ON 19/8/23



SERUM ELECTROLYTES ON 20/8/23


SERUM ELECTROLYTES ON 21/08/23




ECG


HEMOGRAM ON 19/8/23




HEMOGRAM ON 20/8/23









PROVISIONAL DIAGNOSIS

DIABETIC KETOACIDOSIS WITH TYPE 1 DIABETES MELLITUS


TREATMENT (19/8/23)

1) NBM till further orders

2) IV Fluids with NS at 100 ml/hr

3) INJ.HAI 40 IU in 39 ml NS at 2ml/hr to increase or decrease to maintain GRBS between 150-250mg/dl

4) INJ. ZOFER 4mg IV/TID

5)IV fluids 5D at 50ml/hr

6) INJ. NEOMOL 1gm SOS

7) Strict 7point profile charting

8) Monitor vitals and inform SOS

9)INJ. K+ lamp in 250 ml nil/slow( If SERUM K+ =<5mEq/L 

ON 20/8/23

1)IV Fluids with NS at 50 ml/hr

2) INJ.HAI S/C TID 16-16-16

3)INJ. NPH S/C BD 16-x-14

4) INJ. ZOFER 4mg IV/TID

5) TAB. DOLO 650MG PO/SOS

6) Strict GRBS 7point profile charting

7) Monitor vitals and inform SOS

ON 21/8/23

1)IV Fluids with NS at 50 ml/hr

2) INJ.HAI S/C TID 16-16-16

3)INJ. NPH S/C BD 16-x-14

4) INJ. ZOFER 4mg IV/TID

5) TAB. DOLO 650MG PO/SOS

6) Strict GRBS 7point profile charting

7) Monitor vitals and inform SOS

8) Syp. POTKOLR 10ml PO/TID





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