Elog for 20 year old diabetes patient

** This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

 

Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.

 
I have been given the following case to solve, in an attempt to understand  the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings,  Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

CASE SHEET

This is the case of a 20 year old boy who was brought to the ICU after an episode of vomiting 

Chief complaints:

• Severe vomiting , abdominal pain

History of presenting illness:

Patient is a known case of diabetes mellitus(Type 2) since one year. He had presented to the opd with similar complaint 4 months ago where he was also diagnosed with Jaundice

History of past illness:

Patient has been taking insulin injections for a year now

Personal history:

• College student -2nd year degree. Patient says that he has made dietary modifications after being diagnosed with diabetes a year ago. 
• He takes mixed diet but is predominantly vegetarian. He says he has started eating less since being diagnosed with diabetes. 

Family history:

• No relevant family history.

Treatment history:

Insulin injections 3 times a day

16 units at breakfast

10 units at lunch

20 units at dinner

General examination:

Pallor: - Not seen

Icterus: - Observed in bulbar conjuctiva and palms

Cyanosis: - Not seen

Clubbing: - Not seen

Koilonychyia: - Not seen

Lymphadenopathy: - Not seen

Edema: - Not seen

Vitals:

BP: 120/70 mmHg

PR: 127 beats per minute

RR:  27 cycles per minute

Temperature: Afebrile

Respiratory system examination:

Normal vesicular breath sounds heard

No chest wall deformity 

Trachea central

Expansion is symmetrical

Percussion note is resonant

No wheeze or crackles heard.

Vocal resonance normal and symmetrical

Central nervous system Examination :

Conscious and coherent

Motor system reflexes normal.

Speech: Normal

Signs of meningeal irritation absent

Cranial nerves are intact

Gait is normal. 

Investigation :

1.ABG

2.LFT

3. Ketone bodies

4. Hemogram

5. Random blood sugar

6.Blood urea

7. Serum amylase

8.Serum creatine

9. Serum electrolytes

Provisional diagnosis: Diabetic ketoacidosis and jaundice

Treatment: