28 year old with diabetic ketoacidosis

 This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome. 


 I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, and investigations, and come up with a diagnosis and treatment plan.


CASE PRESENTATION:


28 year old female presented with complaints of

      Vomiting 6 days back

      Burning micturition since 5 days

      Shortness of breath since 6 hours

Hopi: patient was apparently asymptomatic 6 days back, then she had vomiting 6-7 episodes of non bilious, non blood stained, non projectile, yellowish to green in color. No h/o diarrhoea

 She had burning micturition since 5 days. Not associated with pain abdomen, fever

 She had shortness of breath since 6 hours, sudden in onset, gradually progressive

 No h/o orthopnea, pedal edema, PND, palpitations, chest pain 


Past history:

K/c/o diabetes type 1 since 2 years and is on insulin 15 units s/c BD

N/k/c/o HTN, epilepsy, TB, Asthma


Personal history:

Takes mixed diet, with normal appetite

Has regular bowel and bladder habits

No addiction

O/E: patient is conscious and coherent

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy

Pitting type of pedal edema present upto knee


Vitals

Temp:96.8F

PR:118 bpm

RR:42 cpm

BP:140/90 mm hg

GRBS: 181 mg/dl


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