A 41 year old female with diabetes, abdominal pain ,nausea and vomiting
A 41 year old female with diabetes, abdominal pain ,nausea and vomiting
July 29,2023
Hi,I am Arundathi Sri 5th semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio.
CASE SHEET
CHIEF COMPLAINTS:
A 41 year old female housewife from Miriyalguda came to casualty with C/O:
Nausea and vomiting since 3days
Abdominal pain since 3days
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 4days back then she developed nausea and vomiting, 8-10 episodes of vomiting, content food material watery, non bilious, non projectile, not blood binged and associated with Abdominal pain of diffuse type and non radiating.
No H/O chest pain, Pedal edema, burning micturition, coughing, palpitations, excessive sweating, giddiness and wheeze
H/o skipping OHAs since 2 days
HISTORY OF PAST ILLNESS:
K/c/o Diabetes Mellitus type 2 since 2 years for which she is on medication (Tab Glimi M1 )
H/o raised blood pressure.
H/o undergoing tubectomy.
No h/o addiction or allergies
DAILY ROUTINE:
Patient initially used to wake up at 5:30 am, now she wakes up at around 6 am. She has idli or dosa for breakfast around 7 am. She then does her household chores and has white rice and curry for lunch at around 1:30 pm. She then continues the house hold work or occasionally watches TV till around 7 pm then she starts preparing and has dinner (white rice/roti/howar roti) and goes to bed by around 9 pm.
GENERAL EXAMINATION
Patient is concious, coherent and cooperative
No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.
Vitals:
BP: 170/110mmhg
PR: 68bpm
RR: 16 cpm
Temp: 97.8 F
GRBS: 200 mg/dl
SPO2: 98% at RA
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM EXAMINATION :
Bilateral air entry +
Normal vesicular breath sounds heard
Trachea central
No added sounds
CVS EXAMINATION :
S1, S2 heard
No murmurs
ABDOMEN EXAMINATION :
Soft, no tenderness
No organomegaly
Bowel sounds - present
CNS EXAMINATION :
Gcs - E4V5M6 (15/15)
Higher mental functions - normal
Cranial nerve examination - normal
Sensory and motor system normal
No signs of meningeal irritation
INVESTIGATIONS:
URINE FOR KETONE BODIES : positive
BLOOD GROUP: B positive
RANDOM BLOOD SUGAR : 200 mg/dl
HEMOGRAM :
CUE:
LFT:
SERUM OSMOLALITY:
BLOOD UREA:
SERUM CREATININE:
SERUM ELECTROLYTE:
ABG:
CHEST X RAY: Normal
ECG
2D ECHO: Normal
ULTRASOUND ABDOMEN:
Impression: Grade 1 fatty liver
PROVISIONAL DIAGNOSIS:
41 year old female diagnosed with Diabetic ketosis with DM type 2.
