A 41 year old female with diabetes, abdominal pain ,nausea and vomiting

July 29,2023

Hi,I am Athram Divya 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.