18YEAR OLD MALE WITH UNCONTROLLED SUGARS
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18 year old male residing at Mungodu (nalgonda) came with c/o
- weight loss and unable to gain weight since 1year
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 1 year back and his sister noticed that he started loosing weight approximately 5-8kg in a duration of a year and not able to gain weight in spite of taking food regularly.
- c/o increased appetite (polyphagia 6-8 meals per day) since 1 year
- c/o polyuria (2-3 times overnight)
- No h/o fever, cough, cold
- No h/o bleeding manifestations, dark coloured stools
- No h/o palpitations, sob, pedal edema
His parents both are stone cutters since his childhood. He used to go along with their parents and used to help them.
PAST HISTORY :
- H/O ? Febrile seizures @ 2 years
- No h/o similar complaints in the past
- No h/o DM, HTN, TB, asthma
FAMILY HISTORY :
No h/o DM, HTN, TB, asthma and epilepsy
BIRTH HISTORY :
Full term normal vaginal delivery
H/o consanguinity +
DEVELOPMENTAL HISTORY :
Delayed milestones
Walking at the age of 3 years
PERSONAL HISTORY :
Diet - mixed
Appetite - increased
Sleep - adequate
Bowel and bladder movements - regular
DIETARY HISTORY :
- Early morning - glass of tea
- Morning for breakfast - rice + cup of curry
- Lunch - rice 2-3 cups + 2 cups of curry
- Dinner - rice 2-3 cups + 2 cups of curry
- In between these meals he also consumes same amount of food with 1-2 cups of curry every 2-3 hrly
- He consumes routinely dal(mostly) also leaf curries, brinjal etc
- He doesn't consume eggs as he don't like them
- Meat ( chicken 1 cup) once in a while of 1-2 months
GENERAL EXAMINATION :
- Patient is conscious, coherent
- No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema
VITALS :
Temp - 98.3 F
PR - 98 bpm
RR - 18 cpm
BP - 100/80 mm Hg
Spo2 - 98% @ room air
GRBS - >450 mg/dl
SYSTEMIC EXAMINATION :
CVS - S1S2 +
RS - BAE+
P/A - soft, nontender
CNS - NAD
Higher motor functions - intact
INVESTIGATIONS :
RBS :
CUE :
THYROID PROFILE:
CHEST X RAY PA VIEW :
SEROLOGY : NEGATIVE
DIAGNOSIS : UNCONTROLLED SUGARS WITH DENOVO DETECTED TYPE 1 DIABETES MELLITUS
ENDOCRINOLOGY REFERRAL :
OPHTHALMOLOGY REFERRAL :
GRBS CHARTING :
PLAN OF CARE :
1. IVF - NS, RL @ 100ML/HR
2. INJ HAI ACC. INFUSION CHARTING
3. HOURLY GRBS CHARTING
4. INJ HAI 6U IV/STAT ACCORDING TO SLIDING SCALE
5. INJ ZOFER 4MG IV SOS
6. STRICT I/O CHARTING