case file

LEW AH KIU, 58 YO, CHINESE, MALAY U/L 1)DM X10 YEARS -FOLLOW UP IN KK SAWAH -RECENT ADJUSTMENT OF OHA IN KK -UNSURE OF THE MEDIACATION 2) HTN

X>10 YEARS -KK FOLLOW UP AND TOOK MEDICATION REGULARLY P/W 1) NOTED BY HUSBAND THAT PATIENT SUDDENLY NOT RESPONSIVE WHEN CALLED AROUND 4 AM ON THE DAY OF ADMISSION. -PATIENT'S HUSBAND BROUGHT HER TO HOSPITAL. -IN A&E, REFLO STAT IS 1.8 -PATIENT WAS GIVEN 50CC STAT AND IVD 10& MAINTENANCE -PATIENT REGEINED CONSIOUSNESS AND ORINETAED TO TIME, PLACE AND PERSON -HISTORY OF TAKING OHA WITHOUT PROPER DINNER LAST NIGHT -CLAIMS DID NOT TAKE MEAL REGULARLY AS SHE TOOK OHA O/E ALERT, CONSCIOUS -GCS FULL -ORIENTATED TO TIME, PLACE AND TIME -SPEAKING IN FULL SENTENCES BP 131/91 HR 93 T 37.8 SPO2 4.4 LUNG CLEAR CVS S1S2 P/A SNT NO PEDAL EDEMA UPON DISCHARGE, -PATIENT IS ALERT AND CONSICIOUS -SUGAR STABLE -ABLE TO TOLERATE ORALLY -NO ACTIVE COMPLAINT BP 114/85 REFLO 7.7 T 34 HR 68 RR 21 LUNG CLEAR CVS S1S2 P/A SNT NO PEDAL EDEMA

DIAGNOSIS HYPERGLYCEMIC ATTACK SECONDARY TO OHA ADJUSTMENT

MEMO TO KK TO REVIEW SUGAR AND TO START BACK OHA IF INDICATED .7 .ATHENOLOL 100MG OD -T.5 TRIGLYCERIDE 1.8 CREATININE 59 FBS 7.2 HBAIC 5.ASPIRIN 75MG OD -T.29 HDL 1.78 LDL 1.1 TWDC 8.12 PHOPATES 1.CA LACTATE 300MG OD -T. CHOLESTEROL 3.TCA KK UPON DISCHARGE.13 UREA 2.8 PLATLETS 46 T.05 ALP 70 ALT 39 T. PATIENT IS GIVEN -T.SIMVASTATIN 20MG ON -T. AMLODIPINE 10MG OD -T. PERINDOPRIL 6MG OD FBC HB 12.8 SODIUM 138 POTASIUM 3.DIABETES MELLITUS HYPERTENSION PLAN . PROTEIN 83 ALBUMIN 40 GLOBULIN 43 T. BILIRUBIN 8 CALCIUM 2.

Sign up to vote on this title
UsefulNot useful