A 55 year old female with DKA with Diabetes mellitus with compound fracture of left lowerlimb with external fixator

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan



A 55 year old female came with C/o fever since 4 days, high grade , relieved on medication.

C/o of SOB since 4 days , progressive in nature

SOB at rest ( Grade 4).

HOPI: The patient was apparently asymptomatic 4 days back then she had a H/o RTA ( Fracture of left lowerlimb) S/p wound debridement with external fixator under spinal anaesthesia)

H/o pus discharge from external fixator site.

Grade 4 SOB progressive in nature ( At rest) a/w lower back ache and generalised body pains.


PAST HISTORY:  k/c/o Diabetes mellitus 2

Not a K/c/o HTN, TB,CVA ,CAD ,Epilepsy ,Asthma

PERSONAL HISTORY:

Diet: Mixed

Appetite: Normal

B&B: Regular 

Addictions: No addictions.

O/E

General examination 

Temp: 98.9 F

PR: 100 bpm

BP: 130/90 mm hg

RR:  22 cpm

SpO2: 98% @ RA

GRBS: 387 mg / dl

Systemic examination 

CVS: S1S2 + , No murmurs

RS: BAE + , NVBS

P/A: Soft , NT

CNS:  No FND

INVESTIGATIONS





















TREATMENT:

IVF NS & RL continuous infusion @ 180 ml/hr

Inj. HAI 8 units/IV/STAT

Inj. HAI 10 ml in 39 ml NS IV @ 6ml/hr

Inj. MEROPENEM 1gm IV/BD

Inj. VANCOMYCIN 1 gm in 100 ml NS IV/BD

Inj. PAN 40mg IV/OD

GRBS Monitoring hourly 

IVF 25% Dextrose if GRBS is more than 150 mg/dl.



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