UNIT 3 ADMISSION

36 M came with the c/o decreasing platelets. 

Bank worker for Nalgonda, had a h/o fever with chills on Friday which resolved on taking mediciation after he was hospitalised on Monday, until yesterday evening. 

He had no h/o SOB, Vomitings, Blood in stools. 

On serial observation of his blood count, there was a significant decrease from 1.6 L (Saturday) to 26000 (yesterday afternoon). 

No h/o any surface / visceral bleeding manifestations. 

Since yesterday, his wife gives history of abdominal distension. Patient complains of SOB after taking food and fluids. 

Patient gives history of ?greenish-dark coloured stools. 

Serial Platelet Count since Saturday

Saturday - 1.6L

Monday - 99k 

Tues - 30k

Wednesday (Afternoon) - 26k

No past medical history. 

Appetite - Normal

Diet - mixed 

Sleep - Normal now, but could not sleep in the first 4 days of fever. So, on monday was administered ?sleeping pills (as per his wife) 

Bowel and Bladder - Regular and passed greenish-dark stools 

General Examination - 

NO pallor/ Icyerus/ Cyanosis/ lymphadenopathy/ Clubbing

Vitals at Presentation 

Temp Afebrile

BP 110/80

PR 75 / min

RR 15 / min

GRBS 121

GCS 15/15 

Spo2 98% on RA 

Resp - BAE + , NVBS 

CVS - S1 S2 heard 

Per Abd - soft, non tender 

CNS - NFND 

Provisional Diagnosis - ? Viral Pyrexia with Thrombocytopenia 

Examintion Day 1 @ 8 A.M 

Subjective - 

1. Abdominal Distension since yesterday

2. Reddish Spots on his chest

3. Mild SOB on consuming food and liquids 

Objective - 

BP 110/80 (All same in supine, standing for 2 minute and 3 minutes) 

PR 60 

Temp - 99.6 

Platelets - 40,000

CVS - S1 S2 Heard 

Resp - BAE + , NVBS 

CNS - NFND 

P/A - Diffuse Tenderness + , Fluid Thrill +, Bowel sounds + 

Day 3

SOAP NOTES 

SUBJECTIVE : No fever spikes 

OBJECTIVE : 

BP - 110/70 MM OF HG(SUPINE) , 100/70 (Standing 1 min and 3 min)

PR 80 BPM

Temp - 98.6 

CVS - S1 S2 Heard 

Rsp - BAE + , NVBS 

CNS - NFND 

PA - Soft, non tender 

ASSESSMENT : 

VIRAL PYREXIA WITH THROMBOCYTOPENIA (DENGUE NS 1 NON REACTIVE) with Platelet count 41,000

Plan : 

1. IVF 1 UNIT NS, RK @ 100 ML/HR

2. TAB. DOLO 650 MG /PO/TID

3. INJ NEOMOL 1 GM IV/SOS IF TEMP >101 F

4. TEMP CHARTING 2 HRLY AMD TEPID SPONGING

5. VITALS MONITORING 5 HRLY

6. INJ PAN 40 MG/IV/OD

7. TAB DOXY 100 MG /IV /OD

8. ZYTE GEL 

9. WATCH FOR BLEEDING MANIFESTATIONS AND POSTURAL HYPOTENSION

UNIT 6 Admission

Patient came to opd with c/o vomitings (in the early hours) since the evening of previous day. 

Pain abdomen (since a day prior to the day of admission)

History : 

Patient, who is a homemaker (inititally labourer in our hospital)  was apparently asymptomatic till 7.00pm then she had sudden onset of vomitings, non projectile , non bilious,contains food particles,.non foul smelling associated with pain abdomen

After 1hr she had another episode till 1am she had 4 episodes of vomitings

Not associated with fever, chest pain, palpitations, loose stools,pedal oedema, blurring of vision

K/c/o DM2(since 5 years)

Since 2years on inj.mixtard (15u--X--10u)

Not a k/c/o htn, asthma, tb, epilepsy

No family h/o DM in immediate family. 

GENERAL EXAMINATION : 

Pt was conscious, coherent and cooperative. Oriented to time, place and person. Moderately built and moderately nourished. 

Vitals at presentation: 

Temp - Afebrile 

BP - 140/80

PR - 90 bpm

RR - 15 cpm

Spo2 - 98% @ RA

GRBS - 588 mg/dl 

CVS - S1, S2 heard, no murmurs

Resp - BAE + , NVBS + 

P/A - Soft, non-tender, no organomegaly, bowel sounds heard 

CNS - NFND

Provisional diagnosis: Diabetic ketoacidosis secondary to gastritis

 Day 1 @ 4;30 A.M.

1. INJ. HAI 6U I.V. STAT FOLLOWED BY INJ HAI 1 ML (40 UNITS) + 39 ML NS @ 6ML/HR TILL

GRBS IS 200 MG/DL

THEN INSULIN INFUSION CONTINUED ALONG WITH 5% DEXTROSE

2. GRBS 1 HRLY

3. IVF 2 UNITS NS AND 2 UNITS RL @ 100 ML/HR

4. I/O CHARTING

Day 1 @ 8:30 A.M

SUBJECTIVE : DECREASED VOMITINGS AND PAIN ABDOMEN

OBJECTIVE :

PT IS C/C WITH

BP - 150/80

PR - 83/MIN

I/O - 1.5L/500ML

GRBS - 128 MG/DL

CVS - S1 S2 HEARD

RESP - BAE +, NVBS

CNS - NFND

P/A - SOFT , NON- TENDER

ASSESSEMNT : DKA SECONDARY TO GASTRITIS

PLAN : NBM TILL FURTHER ORDERS

1. INJ HAI INFUSION @ 2ML/HR + 5% DEXTROSE INFUSION @ 75 ML/HR TILL ACIDOSIS

RESOLVES

2. GRBS 1 HRLY

3. INJ PAN 40 MG I.V. OD

4. STRICT I/O CHARTING

5. BP/PR/RR/TEMP/SPO2 CHARTING 4TH HRLY

Day 1@ 6:00 PM

1. GRBS 6TH HRLY ( 8 AM - 2 PM- 8 PM- 2 AM)

2. INJ HAI S/C TID (PREMEAL) AFTER INFORMING PG

3. INJ PANTOP 40 MG PO OD

4. IVF NS, RL @ 75 ML/HR

Day 2 @. 8.00 a m.

SUBJECTIVE - NO COMPLAINTS

OBJECTIVE -

BP 140/80

PR 84 BPM

I/O 3000ML/2000ML

CVS - S1 S2 HEARD

RESP - BAE +, NVBS

CNS - NFND

P/A - SOFT , NON- TENDER

GRBS @ 8 AM - 351 MG/DL (16 U HAI GIVEN)

GRBS @ 2 PM - 246 MG/DL (14U HAI GIVEN)

ASSESSMENT - DKA SECONDARY TO GASTRITIS

PLAN -

1. INJ HAI S/C AFTER INFORMING GRBS TO PG

2. INJ PAN 40 MG I.V. OD

3. IVF 1 UNIT NS AND RL @ 75 ML/HR

Day 3 @ 8.00 am

SUBJECTIVE - NO COMPLAINTS

OBJECTIVE -

BP 110/70

PR 88 BPM

CVS - S1 S2 HEARD

RESP - BAE +, NVBS

CNS - NFND

P/A - SOFT , NON- TENDER

GRBS @ 8 AM 466(8U HAI ,10UNPH)

ASSESSMENT - DKA WITH DMII SINCE 5 YRS

PLAN -

1. 8 AM - INJ REGULR INSULIN 8U+NPH 10U

 2 PM-INJ REGULARINSULIN 8U

 8PM - INJ REGULAR INSULIN 8U + NPH 10 U

2. IVF 1 UNIT NS AND RL @ 75 ML/HR

Day 4 @ 8 am 

SUBJECTIVE - NO COMPLAINTS

OBJECTIVE -

BP 110/70

PR 88 BPM

CVS - S1 S2 HEARD

RESP - BAE +, NVBS

CNS - NFND

P/A - SOFT , NON- TENDER

GRBS @ 8 AM 350(8U HAI ,8 U NPH)

ASSESSMENT - DKA WITH DMII SINCE 5 YRS

OPTHALMOLOGY REFERREL

PLAN -

1. 8 AM - INJ REGULR INSULIN 8U+NPH 10U

 2 PM-INJ REGULARINSULIN 8U

 8PM - INJ REGULAR INSULIN 8U + NPH 10 U

2. IVF 1 UNIT NS AND RL @ 75 ML/HR

Planning for discharge today. 

Course in the hospital -

PATIENT CAME TO THE HOSPITAL WITH COMPPLAINTS OF VOMITINGS AND PAIN

ABDOMEN. SHE WAS DIAGNOSEDAS DKA WITH DM II SINCE 5 YRS WITHHBAC 6.9 . SHE WAS

TREATED WITHINJ. HAI 6U I.V. STAT FOLLOWED BY INJ HAI 1 ML (40 UNITS) + 39 ML NS @

6ML/HR TILL GRBS IS 200 MG/DL THEN INSULIN INFUSION CONTINUED ALONG WITH 5%

DEXTROSE @ THE TIME OF ADMISSION .

PATIENT SYMPTOMATICALLY IMPROVED WITH DECREASE IN PAIN ABDOMEN AND

VOMITINGS, CONTROL IN GRBS.

Advice on discharge - 

8 AM -INJ REGULAR INSULIN 8U +NPH 8U

2 PM- REGULAR INSULIN 8 U

8PM - REGULAR INSULIN 8U+NPH 8 U