65 year old female with fever and abdominal pain.

A 65-year-old female, housewife by occupation, resident of choutuppal was brought to casualty with chief complaints of 

1. Fever since 3 days

2. Abdominal pain since 3 days 

3. Vomiting since 1 day

4. Shortness of breath since 1 day


The patient was apparently asymptomatic 3 days then she developed fever. The fever was high-grade intermittent associated with decreased food intake not associated with chills and rigors, relieved on taking medication. 

She developed abdominal pain in the epigastric region since 3 days not associated with food patterns relieved on medication. 

4 episodes of vomiting. The content was undigested food, no known aggravating factors, and relieved to medication.

Shortness of breath grade 2 since morning but it is relieved now.


DAILY ROUTINE:

She wakes up around 6 am does daily household chores eats breakfast at 8 am then she doesn't do anything significant she spends time with people around her then she haves her lunch around 1 pm. She sleeps for 2 hours. Then she wakes up and does household chores eats her dinner at 8 pm sleeps at 9 pm.

PAST HISTORY:

No similar complaints in the past

H/o Diabetes (type 2) since 10 years

H/o Coronary artery disease since 1 and half year

No H/o Hypertension, Epilepsy, Tuberculosis 

TREATMENT HISTORY:

Injection mixtard since 10 years

Tablet Ecosprin AV 75 since 1 and half years

PERSONAL HISTORY:

Appetite: Normal

Diet: Mixed

Bowel and bladder movements: Regular

Sleep: Adequate

No addictions

No known allergies

GENERAL EXAMINATION:

Pallor: Absent

Icterus: Absent

Clubbing: Absent

Cyanosis: Absent

Lymphadenopathy Absent

Edema: Absent




VITALS:

Temperature: Afebrile at the time of examination

Pulse rate: 85 bpm

BP: 120/80

Respiratory rate: 18 cpm

CARDIOVASCULAR EXAMINATION:

Inspection: Apical impulse seen

Palpation: Apical impulse 5th intercoastal impulse

Auscultation: S1,S2 heard no murmurs

RESPIRATORY SYSTEM:

Inspection: Chest bilaterally symmetrical, all quadrants move equally with respiration

Palpation: Trachea central, chest expansion normal

Auscultation: Bilateral equal air entry

Bilateral vesicular breath sounds

ABDOMEN:

Soft

No tenderness

No organomegaly

No shifting dullness

No fluid thrill 

Bowel sounds heard

CENTRAL NERVOUS SYSTEM:

No focal neurological deficits

INVESTIGATIONS:

Complete blood picture

Complete urine examination

Urine examination for ketones

HBA1C

Liver function tests

Renal function tests






PROVISIONAL DIAGNOSIS:

Diabetic Ketoacidosis







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