General Medicine 3
July 18, 2022
A 65 YEAR OLD FEMALE PATIENT CAME WITH DRYNESS OF MOUTH AND ABDOMINAL PAIN.
Hi, we, Dussa Sri Snehitha and Gugulothu Soniya , 3rd sem medical students.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.
CASE SHEET:
Chief complaints:
A 65 year old female , home maker by occupation, hailing from chityal, came to casualty on 16 th of July , with chief complaints of :
- fever since 3 days
- abdominal pain since 3 days
- vomitings in the morning
- Shortness of breath
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 3 days ago. The patient was a known case of type 2 diabetes since 10 years. The patient was on medication everyday with insulin injection by patient's husband.
The patient has a history of shortness of breath since 4 months.The patient developed fever dove 3 days, which was intermittent, not associated with chills and rigors. The fever subsided on medication with paracetamol.
The patient has decreased appetite and food intake. She also had vomitings(4 episodes) , undigested food as content of vomit , which was relieved on prescription of a physician.
Then the patient gave complaints of pain in the abdomin above umbilical region. It was not associated with food pattern.
ASSOCIATED DISEASES:
The patient is a known case of type II Diabetes Mellitus for 10 years.
PAST HISTORY:
The patient has a history of coronary artery disease.
PERSONAL HISTORY:
Diet: Mixed
Bowel: Regular
Micturition: Normal
Appetite: Normal
Habits: no addictions
No history of allergy, hypertension, asthama, tuberculosis, epilepsy.
FAMILY HISTORY:
No family history
DRUG HISTORY:
INJ- MIXTARD for diabetes
Tablets- ECOSPRIN 75
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative
No pallor
No icterus
No cyanosis
No lymphadenopathy
No clubbing
No pedal edema
No malnutrition
Mild dehydration
VITALS:
Temperature: 98.6 F
Pulse: 96 beats per minute
Respiratory rate: 21 cycles per minute
SPO2: 96%
GRBS: High
SYSTEMIC EXAMINATION:
Cardiovascular System:
No thrills
Cardiac sounds: SQ and S2 heard
No murumurs
Respiratory system:
Vesicular breath sounds heard
Mild dyspnea
No wheezing
Abdomen:
Shape of abdomen: scaphoid
Tenderness: present-epigastric region
No palpable mass
No bruits
Non palpable liver
Non palpable spleen
Bowel sounds: heard
CENTRAL NERVOUS SYSTEM:
Conscious
Speech-normal
INVESTIGATION:
Complete blood picture:
PROVISIONAL DIAGNOSIS:
Diabetic ketoacidosis
Medication given:
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