Case of a 20 year old male.

THIS IS THE CASE OF A 20 YEAR OLD MALE STUDENT.

CHIEF COMPLAINT

The patient was brought to the casualty with the chief complaint of shortness of breath and vomiting.

HISTORY OF PRESENTING ILLNESS

Apparently 4 months ago he was hospitalised for jaundice and malaria . It was then ,that he got diagnosed with diabetes mellitus type 1. Since then he has been taking Insulin for his treatment.

PERSONAL HISTORY 

DM type 1 present

HTN, TB , Asthma and epilepsy is absent.

Appetite is decreased.

Diet - Non veg mixed diet.

Bowel and bladder movements are normal .

FAMILY HISTORY -

Nothing significant.

VITALS- 

 PR =126 bpm 

 BP= 120/70 mmhg 

RR= 35 /min

 TEMP= 99.6 F

 SPO2= 99% at room air. 

 

GENERAL EXAMINATION

Patient is conscious , coherent and cooperative.

Moderate built .

There is no pallor, cyanosis , lymphadenopathy and clubbing .

Icterus is present.

Mild dehydration.

SYSTEMIC EXAMINATION 

CVS:- 

 S1, S2 heard Palpable 

 

RESPIRATORY SYSTEM :- 

 BAE+ 

 NVBS heard 

 PER ABDOMEN :- 

Soft and mild tenderness present in the epigastric region.

 CNS :- 

Patient is conscious and coherent.

Speech is normal.

Neck stiffness is absent.

Kernig's sign - absent

                       Rt              Lt

Reflexes- B      + +             ++ 

                T       + +             + +

                S      +                + 

                K     +   +           +  + 

                A      -               -

CEREBRAL SIGNS-

Finger nose test in coordination- NO

Knee- Heel in coordination - NO

PROVISIONAL DIAGNOSIS-

Diabetes keto acidosis k/c/o Type 1 DM

TREATMENT

1. Inj HUMAN ACTRAPID I.V

40 units in 40 ml

2. Inj . CEFTRIAXONE 1g/ I.V / BD

3. TEMP CHARTING 4th hourly 

4. Inj OPTINEURON 100 ml NS/IV

5. BP/PR/SpO2 monitoring

6. GRBS monitoring hourly.