15-11-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER 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.
[4:48 pm, 15/11/2025] PPM 1: @PPM3 share the story and the previous EMR summary
[9:42 am, 16/11/2025] PPM 3: Ok sir
[4:57 pm, 19/11/2025] PPM 1: Not sure about the previous EMR summary but shared the latest EMR summary
Age/Gender: 46 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 12/10/2025 06:25 AM
Discharge Date: 15/10/2025 11:02 AM
Name of Treating Faculty
Diagnosis
DIABETIC KETOACIDOSIS SECONDARY TO UROSEPSIS
Case History and Clinical Findings
PATIENT AS BROUGHT TO CASUALTY IN THE STATE OF DYSPNEA.
HOPI: PATIENT WAS APPARANTELY NORMAL THEN SINCE YESTERDAY SHE DEVELOPED SHORTNESS OF BREATH, SUDDEN IN ONSET, GRADE IV, NO H/O ORTHOPNEA, PND,
H/O VOMITINGS, 2 EPIOSDES, WATERY CONSISTENCY, NON BILIOUS, NON BLOOD STAINED, NON PROJECTLE
NO C/O CHEST PAIN, PALPITATIONS, PEDAL EDEMA, FEVER, COUGH, COLD.
PAST HISTORY: K/C/O TYPE II DM SINCE 15DAYS ON REGULAR MEDICATION.
N/K/C/O HTN, CVA CAD TB EPILEPSY THYROID DISORDERS. NO OTHER COMORBIDITIES.
PERSONAL HISTORY: MARRIED, FARMER, NORMAL APPETITE, MIXED DIET, REGULAR BOWEL AND BLADDER. NO KNOWN ALLERGIES
GENERAL EXAMINATION: NO PALLOR, NO ICTERUS, NO CYANOSIS, NO CLUBBING, NO
LYMPHADENOPATHY, NO PEDAL EDEMA.
VITALS: TEMP: AFEBRILE, BP: 110/70MMHG, RR: 19 CPM, PR: 92 BPM, SPO2: 98% AT RA, GRBS: 111 MG/DL .CVS, RS, PER ABDOMEN-NORMAL
Investigation
HEMOGRAM (12-10-25): HB-11.4 PCV- 31.1, TLC-28000, RBC-4.2, PLT-2.7;
CUE:(12-10-25): ALB: +, SUG: NIL, RBC: NIL, PUS CELLS-3-4; LFT (12-10-25): TB-1.34, DB-0.23, SGPT-10, SGOT-12, ALP-229, TP-5.7, ALB-3.25, AG RATIO-1.33, RFT (12-10-25): UR-59, CR-1.9, SODIUM-144, POTASSIUM-3.0, CHLORIDE-104 ,SEROLOGY(12-10-25):HIV, HCV, HBSAG
NEGATIVE.
HEMOGRAM (13-10-25): HB-10.2 PCV- 27.1, TLC-30900, RBC-3.8, PLT-2.2.
RFT (13-10-25): UR-48, CR-2,1, SODIUM-150, POTASSIUM-2.8, CHLORIDE 112.
HEMOGRAM (14-10-25): HB-10.0, PCV- 26.7, TLC-16520, RBC-3.7, PLT-1.5;
RFT (15-10-25): UR-44, CR-1.8, SODIUM-150, POTASSIUM-4.5, CHLORIDE-105
FBS:334, PLBS:420, HBA1C:7.0
UKB-POSITIVE
ABG:PH:7.047, PCO2:14, PO2:39.3<HCO3:3.9
ON 12/10/25: ABG:PH:7.307, PCO2:25.6 PO2:94.8 HCO3:12.4
USG ABDOMEN: GRADE-1 FATTY LIVER
2D ECHO:NO RWMA, EF-67, GOOD LV FUNCTION
Treatment Given (Enter only Generic Name)
1. IVF NS/IV/STAT
2.INJ. HAI 1ML IN 39ML NS INFUSION FOR 1 DAY
3.INJ.MONOCEF 1GM IV/BD
4.INJ.PANTOP 40 MG IV/OD
5.INJ.ZOFER 4MG IV/BD
6.SYP.POTKLOR 10ML PO/TID 10ML--10ML--10ML
7.TAB.GLIMIPERIDE 2MG+METFORMIN 500MG+VOGLIBOSE 0.2MG PO/OD/8AM FOR 1 DAY
8.TAB.GLIMIPERIDE 1MG+METFORMIN 500MG+VOGLIBOSE 0.2MG PO/OD/8PM FOR 1 DAY
9INJ HAI S/C TID 12U--12U--10U
10.INJ.NPH S/C BD 10U--X--10U
Advice at Discharge
INJ MIXTARD 30/70 S/C BD 18 U (8AM)-0-12 U (8PM)
TAB METFORMIN SR 500MG PO /BD 8 AM-0-8 PM
STRICT DIABETIC DIET
HYPOGLYCEMIC SYMPTOMS EXPLAINED
Follow Up
R/A 1 WEEK TO GM OPD
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
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date:15/10/25 Ward: FMW Unit:1
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[5:50 pm, 19/11/2025] PPM 3: I shared it to you
[5:50 pm, 19/11/2025] PPM 3: I have*
[5:50 pm, 19/11/2025] PPM 3: Old summary
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