PATIENT WAS BROUGHT TO THE CASUALITY WITH COMPLAINTS OF PAIN ABDOMEN

 Case History and Clinical Findings

PATIENT WAS BROUGHT TO THE CASUALITY WITH COMPLAINTS OF PAIN ABDOMEN

AND VOMITINGS SINCE 23-4-23 4PM

HOPI-

PATIENT WAS APPARENTLY NORMAL UNTIL 23-4-23 4PM SINCE THEN SHE DEVELOPED PAIN ABDOMENWHICH IS INSIDIOUS IN ONSET ,GRADUALLY PROGRESSIVE ,SQUEEZING TYPE OF PAIN

ASSOCIATD WITH VOMITINGS WHICH ARE 2 EPISODES ,NON PROJECTILE,MUCOID,WITH FOOD PARTICLES AS CONTENT

H/O NAUSEA PRESENT,SHORTNESS OF BREATH PRESENT GRADE-2

H/O FEVER SINCE 1 DAY HIGH GRADE ,INTERMITTENT,NOT ASSOCIATED WITH CHILLS AND RIGORS,RELIEVED BY MEDICATION

PAST HISTORY-

K/C/O DIABETES MELLITUS T-2 SINCE 20 YRS AN DON MEDICATION[UNKNOWN]

N/K/C/O HTN,TUBERCULOSIS,EPILEPSY,CVA,CAD,THYROID DISORDERS

PERSONAL HISTORY-
DIET: MIXED
APPETTITE:NORMAL
BOWEL AND BLADDER: REGULAR
SLEEP: ADEQUATE
NO ADDICTIONS

GENERAL EXAMINATION-PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE
WELL ORIENTED TO TIME,PLACE,PERSON
MODERATLY BUILT AND NOURISHED

VITALS-
TEMPERATURE-AFEBRILE
PR-88BPM
BP-130/70
RR-18CPM

SYSTEMIC EXAMINATION-
CVS-S1S2 HEARD,NO MURMURS
RS-BAE+,NVBS HEARD
CNS-NFND,HMF INTACT
P/A-SOFT,NON TENDER,NO ORGANOMEGALY

Diagnosis:-
DIABETIC KETOACIDOSIS
K/C/O DIABETES MELLITUS T2 SINCE 20 YRS

Investigation
ECG-NORMAL SINUS RHYTM
ULTRASOUND-NO ABNORMALITY DETECTED
HAEMOGRAM
24/4/23
HB 8.9
TLC 30,500
NEUTROPHILS 89
LYMPHOCYTE 06
PCV 31
MCV 91.4
MCH 26.3
MCHC 28.7
RBC 3.3 MILLION/CUMM
PLT 3.1LAKHS/CUMM

Treatment Given(Enter only Generic Name)
SOFT DIET
IV FLUIDS NS@75ML/HOUR
INJ.PIPTAZ 4.25GM /IV/BD
INJ.PAN 40 MG/IV/OD
INJ.ZOFER 4 MG/IV/SOS
INJ.HAI S/C TID[BEFORE MEALS]
INJ.NPH S/C BD [BEFPRE MEALS]
T.PCM 650MG/PO/TID
GRBS 7POINT PROFILE MONITORING
BP MONITORING 2ND HOURLY
STRICT I/O CHARTING
SYP.ASCORIL-D 2.5ML/PO/TID
SYP.CITRALKA 10ML/PO/TID IN 1 GLASS OF WATER

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