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I am Nomika Alli (Roll no 179) of 8th Sem MBBS.
A 20yr old Male , driver by occupation R/o Nalgonda came to the OPD on 18th Aug 2023 with c/o fever since 2 days and vomiting since 6 hours.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 days back and then he developed fever which is low grade not associated with chills and rigors , relieved with medication.
No diurnal variation.
H/o 3 episodes of Vomiting since 6 hours. contains food material, blood tinged, non bilious, non projectile.
Skipped one dose insulin last evening.
No H/O loose stools, pain abdomen, giddiness.
No H/O cough, burning micturition.
HISTORY OF PAST ILLNESS:
K/C/O DM type I since 2 yrs.
HAI 140----140----140
NPH 260---x---260
N/K/C/O HTN, TB, Asthma, CAD, CVD, Thyroid, Epilepsy disorders
TREATMENT HISTORY:
DM TYPE I medication since 2 yrs
SURGICAL HISTORY: NO
FAMILY HISTORY:
N/K/C/O DM, HTN, TB, Asthma, Thyroid, CAD, CVD, Stroke, Cancers, Hereditary diseases, sibling histories
PERSONAL HISTORY:
Unmarried
Driver by occupation
Diet: mixed
Appetite: normal
sleep: adequate
Bowel and bladder : regular
Addictions: no
Allergies: no known
GENERAL EXAMINATION:
Ht: Wt:
Patient is conscious, coherent and cooperative to time, place and person.
No pallor
No icterus
No clubbing
No cyanosis
No koilonychia
No lymphadenopathy
No edema
Vitals: Temp:96.8F
BP: 130/70mmHg
PR:104 bpm
RR: 22 cpm
GRBS: 311mg%
SpO2: 98%
SYSTEMIC EXAMINATION:
CVS: SI S2 heard
no thrills
no murmurs
RS: Dyspnoea present
no wheeze
central position of trachea
normal vesicular breath sounds +
ABDOMEN: Shape: scaphoid
no tenderness
normal hernial orifices
no free fluid
no bruits
liver and spleen not palpable
bowel sounds not heard
CNS: conscious
normal speech
no neck stiffness
kernig's sign negative
cranial nerves, motor system , sensory system: intact, normal
Glasgow scale: E4V5M6
Cerebellar signs- no
finger nose in coordination: yes
Knee heel in coordination: yes
GAIT: normal
MUSCULOSKELETAL SYSTEM: normal
PROVISIONAL DIAGNOSIS:
DIABETIC KETOACIDOSIS with TYPE I DM
PHYSICAL EXAMINATION:
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