a case of 26yr old male

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 available 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-centered online learning portfolio and your valuable inputs on the comment box.

Our patient here is a 26 yr old male,  a resident of suryapet , had come wt  complaints of loose  stools since the past  20 days.
 Pt was apparently asymptomatic 2 months ago ,  then he developed bilateral flank pain.  He  also developed loose stools which were insidious in onset with 4-5 episodes per day( 10 days liquid consistency, 10 days hard consistency)  and was suffering from generalized body weakness since 3 months, which was not associated with nausea, vomiting, Fever.
He is a known case of DM since 3 years ( on irregular medication stopped taking insulin 7 months ago)  
No h/o of htn, tb, epilepsy
K/c/o of polio

Soap notes
 20/08/2022
Pt c/c/c
Temp: afebrile 
Bp: 110/ 70 mmHg
PR: 90bpm
RR: 18 cpm
CVS: S1 S2+
CNS: NAD
Lungs: BAE+ 
GRBS : high

Fever chart




                                  LFT 

RFT


 URINARY KETONES



HEMOGRAM 



CUE 

GRBS
19/08/22 high

20/08/22

2am: 218mg/dl
7am: 141mg/dl
7:00pm : 384 mg/dl




21/08/2022
12:00 am: 347mg/dl
7am: 88 mg/dl

 Provisional diagnosis:  chronic diarrhea under evaluation 
Plan of treatment:

1.IVF-2× NS @75 ml/hr
          2× RL@75ml/hr
2.INJ.HAI 6U IV STAT
3.GRBS 7 POINT PROFILE          
4.BP/PR/TEMP CHARTING 8th hourly




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