A Harikrishna

     GENERAL MEDICINE CASE SHEET(june14)

CHIEF COMPLAINTS: A 35 year old female, fertilizer factory worker by occupation came to the opd with chief complaints of altered sensorium,lack of energy,fever and loss appetite for 3days,vomiting frequently.

HISTORY OF PRESENT ILLNESS:

                 Known case of hypertension().. and recently diagnosed with severe diabetes  and hypersalivation

fever-low grade.

She quit her job 15 days before the development of symptoms and attended to a function 3days before the development of symptoms.

HISTORY OF PAST ILLNESS:

k/c/o :HTN

Not k/c/o: diabetes 

surgical history: umbilical hernia 

PERSONAL HISTORY:

Diet:mixed

Appetite:decreased

Bowel and bladder mixed: normal

Addictions: none

FAMILY HISTORY:

normal 

GENERAL EXAMINATION :

Pallor:not seen

Cyanosis:not seen

Icterus:not seen 

Lymphadenopathy:not seen

Clubbing:not seen

Oedema:not seen

VITALS :

Temperature: febrile 

Pulse rate: 100/min 

Respiratory rate : 22/min 

BP: 140/90

SpO2 : 94%

SYSTEMIC EXAMINATION: 

CVS : 

S1 S2 heard 

Abdomen:

                      

        

PROVISIONAL DIAGNOSIS:

     UNCONTROLLED DIABETES 

INVESTIGATIONS :

TREATMENT:

Treatment history:13/6/22

IVF NS@100ml 

Inj Human Actrapid (1ml+39ml NS)@6ml/hr

Inj Monocef@1 gm x IV x BD

14/6/22

IVF20NS@100ml/hr

Injection human actrapid insulin

                  1ml +39ml NS @ 6ml/hr

GRBS 1hourly

Injection monocef 2gm×IV×BD

Monitor vitals hourly

Injection zoter 4mg IV  BD

Injection pan 40mg IV BD