GENERAL MEDICINE BLOG 4

July 19, 2022. (GM )
A 49 YEAR OLD MALE PATIENT CAME WITHSEVERE VOMITINGS AND HIGH BLOOD SUGARS.

Hi, I am G.soniya  3rd sem medicalThis is an online elog book to discussour patients health data after taking herconsent.This also reflects my patient centeredonline learning portfolios

CHIEF COMPLIONT:

A 47 year old male  driver by occupation came with the c.c of 
vomitings since 2:00 a.m.-( 8-10 episodes)
 
HoPi:The patient was apparently asymtomatic 10 years back then he had fevar generalized weakness for which he got checked with the local doctor and he daignosed with type 2 DM and started with OHA 
A year later he developed head ache was daignosed with hyper tension for which he used medication for an year and stopped them
15 days back the pt had symptoms of headache with blockouts he also developed vomiting 3 to 4 episode s for which he went to a local hospital and daignosed with acute ischemic stroke
 
A day back the pt woke up in the middle of night at 2' clock and had vomiting 8 episodes followed by dizziness 

ASSOCIATED DISEASE: The pt is a known case of type 2 DM 

Past history ; the pt is a known case of acute ischemic stroke and DM 
No history of allergy
No history of asthama
No history of TB
No history of epilepsy
Personal history:
 
Diet mixed
Appetite normal
Habits : regular alcohol intake  smoking 
Bowel blader movement regular
Micturation normal

Family history; 
 Known history of DM in patient of the parents

Drug history; 
Tab metformin _500 mg for 10 years

General examination; 
Moderetally nourished and built
No paller
No icterus
No cyanosis
No lymphadenopathy
No pedal edema
No clubbing of fingers

Vitals;
Tem 98.8'f 
Pulse: 106 BPM
RR      : 20 cpm
BP.      ; 160/100
Spo2.  : 98%

Systemic examination:

Cvs;   no thrills
            Cardiac sounds: S1 S2 heard 
             No murmure s
Rs;        no dyspnea
               No wheezles  
               Breath sounds heard 
Abdomen: no free fluid
                   No palpable mass                                            pain squeezing type of pain 
CNS :.     C .C .C 
                 Speech normal 
Investigation 

Ecg



Abg



Complete blood picture 



Colour Doppler 2d echo :
Daignosis: daibetic ketoacidosis 

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