Short case

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A 50 year old male is presented to OPD with chief complaints of altered sensorium, fever and  vomitings since 5 days.

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 10 years back then he developed giddiness on routine check up and was diagnosed with diabetes.

Patient had 4 months back injury to left foot with small ulcer which progressed and amputation of last 3 toes of the foot.

5 days back he went to brother's home as there was a party, he had mutton curry he skipped taking medication then behaviour of patient was abnormal and had a episode of vomiting which is non bilious and non projectile

And since 15 yrs patient is on medication 

HISTORY OF PAST ILLNESS-:

Patient is Diabetic since 10 years

No history of hypertension, tuberculosis, epilepsy

Patient has no history of drug allergies

PERSONAL HISTORY-:

Diet-mixed

Appetite-lost

Bowel and bladder movement-normal

 Micrurition-normal

Sleep-inadequate 

Alcohol- occasionally

FAMILY HISTORY-:

No member in the family has similar complaints.

TREATMENT HISTORY-:

Patient has history of amputation of last three toes of left foot.

GENERAL EXAMINATION-:

Patient is conscious,coherent and cooperative.

There is sign of pallor

There is mild dehydration 

There is no sign of icterus, cyanosis, clubbing, generalised  lymphadenopathy

VITALS :

Temp :febrile 

Pulse rate:91bpm

Respiratory rate:24cpm

Bp:220/100 mm/hg

Spo2-97%

GRBS-524mg/dl

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM

Inspection: 

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation:

JVP - normal

Apex beat : felt in the left 5th intercostal space

In midclavicular line 

Ausculation:

S1 ,S2 Heard

RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea- central

Normal vesicular breaths heard

No added sounds

PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

No palpable mass or free fluid 

CENTRAL NERVOUS SYSTEM

Patient is conscious 

Reflexes are normal 

Speech is normal

Provisional diagnosis-:

Diabetic ketoacidosis 

INVESTIGATION-:

Treatment