66 KVN SUDHEER

CHEIF COMPLAINTS: 
Decrease in urine output (since 10 days), pedal edema ( since 1 month ) , SOB (  Grade 2-3 ) , swelling of lips (since 3 days )

HOPI: 
•Patient was apparently asymptomatic 11 years back,  then her parents noticed she was eating alot and  had increased  frequency  of   urination 

•she was diagnosed with TYPE 1 DM  ( since then on insulin )

•Patient became drowsy and brought to hospital , diagnosed with DKA ?? and on MIXTRAD (18 units morning , 12 units night )

• 1 year ago she got married and 6 months ago she was brought to hospital as she c/o fever , not eating food for 5 days - diagnosed as HYPERTENSIVE (on TELMISARTAN 40 mg since then ) 

•8 months ago she was UPT positive and had an abortion 2 months ago as foetal cardiac activity was absent 

H/O PAST ILLNESS : 
K/O DM , HTN 
No H/O ALLERGY, ASTHMA, TB 

PRESENT HISTORY: 
Diet: mixed
Appetite: normal
Bowel and bladder movements :Normal
Sleep: adequate
No known allergies
Addictions : ALCOHOLIC ( regularly) 

FAMILY HISTORY: 
 Nil significant 

TREATMENT HISTORY: 
She is on insulin since 11 years and on METAPROLOL 40 mg since 6 months 

GENERAL EXAMINATION:
  •Patient is examined in a well lit room after obtaining consent
•Patient is conscious, coherent, cooperative.
 •Well built and well nourished.
• pallor absent 
•Icterus,clubbing, cyanosis, koilonychia, edema are absent

•VITALS 
Temp- Afebrile 

Bp-150/90 mm hg

PR- 96bpm

RR-24CPM

Spo2- 96% on RA

GRBS : 315 mg/ dl


 SYSTEMIC EXAMINATION :

RS- bilateral air entry present 

CVS : S1, S2 + no murmurs 

P/A- soft and non tender
      bowel sounds present 

CNS : No focal neurological defeicit 
HMF intact 
Power in B/L upper and lower limb Is 5
Reflexes are present with B/L plantars and flexors
 
INVESTIGATION: 

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