SUPRIYA GAGIREDDY 42

Hi,I am supriya 5th sem medical student.This is an online elog book to discuss our patients 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 problems with collective current best evidence based inputs.This E-log book reflects my patient centered online learning portfolia.

Case details:A patient aged 55years , resident of chimiryala, who runs a shop by occupation came to the opd with chief complaints of:
-uncontrolled high sugar 
-shortness of breathe since morning
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 12years bacK and developed lower abdominal pain for which she visited near by hospital for which hysterectomy was done. 11years back she developed excess urination of burning micturition For which she visited hospital and diagnosed as diabetes mellitus type 1 and kept on mixtard insulin since then and she is on regular medication. Since 1year she is having frequent urination for which she visited Hospital. Since 2months she is using oral hypoglycemic agents and mixtard insulin. Last month she has severe vomiting and diarrhea for which conservative therapy has given. 2months back she developed generalized weakness for which she diagnosed as right pyelonephritis -e. Coli and treated conservatively. 


PAST HISTORY
Diabetes since 11years.
Hysterectomy 12years back. 
Not a known case of TB, asthma, epilepsy, hypertension


PERSONAL HISTORY
Married
Vegeterian
Occupation:shop owner
Bowels :regular
Appetite:normal
Micturition:normal
No allergies
No addictions


TREATMENT HISTORY
Mixtard insulin since 11years



FAMILY HISTORY:
No significant family history




GENERAL EXAMINATION
On presentation:patient is conscious and responding when calls with inappropriate sounds. 
No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy 
No edema
No malnutrition
Mild dehydration


VITALS 
TEMPERATURE-98. 6°c
BP-120/70mm of hg
PR-
GRBS : 
Spo2:
B. SYSTEMIC EXAMINATION
Patient was examined in a well lit room after taking the proper concern. 

CARDIOVASCULAR SYSTEM
S1, S2 +ve. 
No murmers

RESPIRATORY SYSTEM
BAE +ve
Normal vesicular breathe sounds heard

PER ABDOMEN
Soft, non tender, not palpable

CENTRAL NERVOUS SYSTEM
Conscious
Normal speech
No neck stiffness
No kernings sign
Cranial, motor, sensory systems :NAD

REFLEXES
Normal reflexes


INVESTIGATIONS
12/7/22
PH:6.99
Pco2:7.9
PO2:13.3
SpO2:92
Hco3:5.1

13/7/22
PH:7.37
Pco2:34.24
PO2:19.8
SpO2:94.5
Hco3:20.4

14/7/22
PH:7.42
Pco2:36.7
PO2:12.8
SpO2:97
Hco3:23.6
15/7/22
PH:7.46
Pco2:41.1
PO2:30.6
SpO2:96
Hco3:29.3

GRBS
12/7/22

14/7/22
GRBS-399mg/dl
Hba1c-7. 4

15/7/22
GRBS-158mg/dl

ULTRASOUND
TPR CHART
ECG

Serum amylase:164
Serum osmalality:315
Serum lipase:38

PROVISIONAL DIAGNOSIS
Diabetes ketoacidosis DM II

TREATMENT

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