THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
EMR SUMMARY
Age/Gender: 43 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 06/10/2025 03:29 PM
Name of Treating Faculty
(AP)
Diagnosis
DIABETES KETO ACIDOSIS
DENOVO TYPE 2 DIABETES MELLITUS
Case History and Clinical Findings
C/O POLYURIA SINCE 20 DAYS INSIDIOUS IN ONSET, 15 TIMES/DAY, 10 TIMES IN NIGHT
ASSOCIATED WITH POLYDIPSIA, INTERMITTENT, URGENCY, INCONTINENCE. NO OTHER
COMORBIDITIES.
PERSONAL HISTORY: MARRIED, NORMAL APPETITE, MIXED DIET, REGULAR BOWEL AND POLYURIA, REGULAR ALCOHOL CONSUMPTION SINCE 20 YRS 90ML/DAY.NO KNOWN
ALLERGIES
GENERAL EXAMINATION: NO PALLOR, NO ICTERUS, NO CYANOSIS, NO CLUBBING, NO
LYMPHADENOPATHY, NO PEDAL EDEMA.
VITALS:- TEMP: AFEBRILE, BP: 100/70MMHG, RR: 12 CPM, PR: 80 BPM, SPO2: 100% AT
RA, GRBS:MG/DL .CVS, RS, PER ABDOMEN, CNS - NORMAL.
Investigation
HEMOGRAM (7-10-25): HB-12, PCV-35.2, TLC-7200, RBC-3.9, PLT-3.3
CUE:(7-10-25): ALB: ++, SUG: NIL, RBC: NIL, PUS CELLS-3-4, EPITHELIAL CELLS:2-3
FBS (7-10-25): 207MG/DL
LFT (7-10-25): TB-0.74, DB-0.19, SGPT-21, SGOT-18, ALP-110, TP-6.7, ALB-4.2, AG RATIO-2.35
RFT (7-10-25): UR-36, CR-1.20
SERUM ELECTROLYTES (8-10-25): SODIUM-142, POTASSIUM-3.5, CHLORIDE-101
Treatment Given (Enter only Generic Name)
IV FLUIDS NS 100 ML/HR
Page-2
KIMS HOSPITALS
INSULIN INFUSION @4ML/HR
INJ HAI S/C 8 U (8AM)-8U (1PM)-8U(8PM) TID
INJ NPH S/C BD 6U(8AM) - 0 -6U(8PM)
,STRICT DIABETIC DIET,
Advice at Discharge
STRICT DIABETIC DIET
INJ HAI S/C 8 U TID (8AM)-8U (1PM)-8U(8PM)
INJ NPH S/C BD 6U(8AM) - 0 -6U(8PM)
TAB VYSOV M 50/500 P/O BD 8AM-0-8PM
Follow Up
REVIEW AFTER 10 DAYS WITH FBS, PLBS REPORTS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
For Treatment Enquiries Patient/Attendant Declaration: - The medicines prescribed
and the advice regarding preventive aspects of care, when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE S
IGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date: 9/10/25
Ward: MMW
Unit: GM I
[10-10-2025 13.02] PPM 1: Afternoon session:
Here's the other 45M with denovo diabetes, Hba1c of 13 and DKA!
He's also quite lean without trunkal obesity and I hope to share his details tomorrow
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