GM case -1
GM case 1
Feb 14 ,2023
18 yr girl come with a complaints of swelling with pus and bloody discharge and associated with fever
Case scenario:
My self Anu Bandlagudem of 3rd BDS .This is an online E log book to discuss our patients de- identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patients problem through series'of inputs from available global online community of experts with aim to solve those patients clinical problems with collective current best evidence based inputs.
I have been given this case to slove in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, findings, investigations, diagnosis and treatment plan.
•Chief complaint:
Swelling with pus and discharge associated with fever,loss of weight, weakness.
Duration: shortness of breathing for 2 days
Fever since week.
•History of present illness :
Patient was apparently asymptomatic 1 week ago and then developed swelling with pus and bloody discharge associated with high grade fever associated with chills and rigor and developed nausea .
•History of past illness :
At the age of 6 yrs visited local hospital and
got to know GRBS high and diagnosed with Diabetes mellitus and started insulin injections.
• Personal history :
Student
Diet: Mixed
Appatite: good
Sleep: good
Bowel movements : regular
Micturation : Good
Addictions:No
•Family history :
No significant family history
• General examination :
Thin built and thin nourished
Pallor - No
Icterus - No
Cyanosis - No
Clubbing - No
Lymphadenopathy- No
Edema- No
•
• Vitals:
Temperature: 98.6 f
Pulse rate : 102 per min
Respiration rate: 36per min
Bp: 130/80mm hg
Spo2 at room temp: 100%
GBRS: 348mg/dl
• INVESTIGATIONS:
• Provisional diagnosis:
Diabetic ketoacidosis
Questions:
Does diabetes keto acidosis affect other systems??
If insulin injection dose taken high doses..wt are the consequences???
Alternative for insulin?? In treatment
Correction of acidosis by which substance??
It can be cured or remains permanently??
