1597 S. Parkview Dr, Park City, UT 84111
Physician’s Progress Notes
S: This 18 y/o F is seen in the office, c/o nausea and vomiting for the past six hours. She is accompanied by her sister, who provides much of the history. Pt. reports a severe headache, and states she feels like she has in the past when she was on the verge of a coma. She was diagnosed with IDDM at the age of 10 and has taken insulin ever since. She is on an 1800 cal. diet. She uses an Accu-Chek at home and evaluates her glucose levels bid. She reports that her levels have been around 60 to 70 for the past four days. Two days ago she had an episode where she felt shaky, anxious, and confused. She had palpitations, was sweating, and felt weak. She has not taken her insulin since that time.
O: T 96, P 105, R 22, B/P 120-66. Skin is warm and dry. Xerosis of hands, arms and perioral area. Odor of ketones is detected in the breath. Biochem results: sodium 125, potassium 4.2, chloride 101, CO2 10, glucose 412.
A: Diabetic ketoacidosis.
P: 10 units regular insulin stat.; check BS in 1h., then q4h; urine checks for sugar, acetone, and volume q voiding; admit to Summit Medical Center.