patient was apparently asymptomatic 6 months back and developed left lower limb pain while walking for a short distance and can't walk due to pain and after taking rest the pain was relieved and resumed his walk and has to take multiple breaks to complete his full path
Past History
He was diagnosed as DM II 15 yrs back(as he was admitted to hospital for fever) and is on oral medication and later shifted for insulin therapy
8yrs back he developed decreased urine output for which he got admitted to the hospital and diagnosed for renal calculi for which he got operated
7yr back he got his right great toe amputated I/V/O ?leprosy (decreased sensations on right foot)
2 years back he got left eye operation ? cataract
His right eye got delayed due to high sugars
Personal history
Diet: mixed
Appetite:normal
Sleep: adequate
Bowel & Bladder: regular
Addiction:
Smoking 3-5ciggs/day since he was 30yrs of age
Stopped 2yrs back
Alcohol since 30yrs of age only on occasions
O/E
Pt is c/c/c
No signs of pallor, icterus, cyanosis, clubbing, lymphadenoapathy, edema
Vitals:
Temp:97.5f
PR: 92 bpm, regular
RR: 26 cpm
BP: 140/70 mmHg
SPO2:
AT ROOM AIR-96%
GRBS:126 mg/dl
Systemic examination :
CVS:S1,S2 heard
Apex beat:5th ICS
Resp:
BAE+(vesicular breath sounds)
Nvbs heard
Position of trachea- central
P/A: soft, tenderness absent, bowel sounds heard
Cns: NFND
On day 1 of admission
Patient developed high sugars during night time and was shifted to ICU for the same
Rx:
1. IVF NS, RL@100ml/hr
2. Inj.HAI S/C premeal TID
8am--1pm--8pm
3. Tab.MVT PO/OD
4. Temp charting 4th hourly
Day 2:
SUBJECTIVE:
NO SUBJECTIVE COMPLAINTS
OBJECTIVE
Temperature-97 F
Bp-120/60 mmhg
PR- 72bpm
RR -11 cpm
GRBS - 196 gm/dl(14IU HAI)
CVS:S1,S2 heard
Apex beat:5th ICS
Resp:BAE+(vesicular breath sounds)
Nvbs heard
Position of trachea- central
P/A: soft, tenderness absent, bowel sounds heard
Cns: NFND
ASSESSMENT-
Uncontrolled Sugars with K/C/O DM II
PLAN OF CARE-
1. IVF NS, RL@100ml/hr
2. 2. Inj.HAI S/C premeal TID
3. 8am--1pm--8pm
4. 3. Tab.MVT PO/OD
5. 4. Temp charting 4th hourly
Day 3
SUBJECTIVE:
NO SUBJECTIVE COMPLAINTS
OBJECTIVE
Temperature-97 F
Bp-120/60 mmhg
PR- 72bpm
RR -11 cpm
GRBS - 196 gm/dl(14IU HAI)
CVS:S1,S2 heard
Apex beat:5th ICS
Resp:BAE+(vesicular breath sounds)
Nvbs heard
Position of trachea- central
P/A: soft, tenderness absent, bowel sounds heard
Cns: NFND
ASSESSMENT-
Uncontrolled Sugars with K/C/O DM II
PLAN OF CARE-
1. IVF NS, RL@100ml/hr
2. Inj.HAI S/C premeal TID
8am--1pm--8pm
4.Tab.MVT PO/OD
5. Temp charting 4th hourly
