This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.
53yrs old female who is homemaker and resident of Cherlapalli complains of giddiness since 3 days and abdominal pain since 3days
Case timeline: JUNE 2010: Patient experienced giddiness following which she lost consciousness and attenders noticed a deviation of her mouth to right. No seizures were noted.
She was taken to a local hospital and was admitted in ICU where high blood sugar was detected and the patient was duly informed regarding her condition. She was discharged after 20 days after her admission in the general ward and was given insulin
NOVEMBER 2010: She was once again reported to have uncontrolled blood sugar and was admitted in the general ward for 2 days following which she was prescribed oral hypoglycemic drugs and discharged. She has been on oral hypoglycemics since then.
APRIL 2021: The patient experienced giddiness and was taken to the hospital where she was diagnosed with a PCA stroke
SEPTEMBER 2021: She reported the sudden onset of a headache which was continuos in nature. A CT scan was done
NOVEMBER 2021: A repeat CT was done in November 2nd for her persistent complaint about the headache.
NOVEMBER 24th: Patient was brought to our hospital and has been complaining of giddiness since 3 days, and transient abdominal pain since 3 days
Tested on arrival:
FBS- 415
PLBS- 582
HBA1C- 8.5
The patient did not want to get admitted so her medication was switched from OHA to tab glimi m2. BD
since 3 days, patient has been on inj human mixtard- 12U----x----5U
no c/o fever, sob, cough, burning micturition.
K/c/o- DM2 on tab glimi m2 bd, on insulin since 3 days
not a k/c/o htm, cva, ba, tb, epilepsy
PAST HISTORY
No similar complaints in the past.
H/o Diabetes mellitus since 10 years
History of PCA stroke 8 months ago
No H/o TB, HTN, Asthma, epilepsy
PERSONAL HISTORY
Appetite:Normal
Diet: Mixed
Sleep:Adequate
Bowel and bladder:Regular
No known drug allergies, addictions
GENERAL EXAMINATION
Patient is conscious, coherant, cooperative, well oriented to time, place and person.
Moderately built and nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
VITALS:
Temperature: Afebrile
PR: 77 bpm
BP: 130/80 mmHg
RR: 19 cpm
SpO2: 98%
GRBS: 584mg/dl
SYSTEMIC EXAMINATION:
RS: BAE+, NVBS+
CVS: S1, S2 heard, no murmurs
P/A: Distended, soft, non tender
CNS: NAD
INVESTIGATIONS:
1) ECG
2) CXR
PROVISIONAL DIAGNOSIS:
An exacerbation of diabetic ketoacidosis in a 52 year old with a history of stroke in the posterior cerebral artery 8 months ago
TREATMENT:
INJ Avil 2cc iv stat
INJ Levipil 1 gm iv stat
INJ Zofer 8mg iv sos
INJ Pan 40 mg iv
INJ HAI 6 unit iv stat followed by 6ml/hr infusion
GRBS charting hourly
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