Patient Name:  Dianne Tell

Patient ID: 3413758

Admission Date: 4/10/xx

DOB: 07/27/XX

Chief Complaint: Confusion, frequent urination, and hyperglycemia

History of Present Illness: Dianne Tell is a 26 yr old who presented to the ER with slight confusion, frequent urination and hyperglycemia.  Urine was found to have increased levels of ketones.

 

Medical History:  IDDM

Medications: Insulin, captopril

Allergies: Demerol


Social History: She does not drink or smoke

Family History: Married.   

Physical Examination:

General:  This is a female who has slight confusion, Ht: 65 in Wt: 70 kg

Vital Signs: Blood Pressure 140/80, heart rate 90, Respiration 28, Temperature 101.2°F

HEENT: Clear

Lymph: Unremarkable

Neck: No goiter, no jugular venous distention

Chest: Clear

Heart: Regular rate and rhythm, no murmur, rub or gallop

Abdomen: Soft and tender

Genitourinary: tender

Rectal: Unremarkable.                                  

Skin: pale, moist mucous membranes. Skin turgor within normal limits.

Laboratory and X-ray Data: sodium 134, Potassium 4.5, glucose 616, BUN 32, creatinine 1.1, white count 16000, Hemoglobin 12, Hematocrit 36, platelets 210.  Urinalysis shows elevated ketones

 

Impression:

  1. Diabetic Ketoacidosis
  2. UTI

Plan:

  1. Admit to ICU
  2. Place on insulin drip
  3. Start antibiotic therapy
Last modified: Tuesday, March 31, 2020, 5:50 PM