EHR extract

myEHR
M_Wormwood_Oct_2_2021
H_James_Feb_10_2021
D_Beckham_May_2_2021
<Note> <Section>Reason for referral <p>Suspected Diabetic Ketoacidosis (DKA)</p> </Section> <Section>Chief complaint <p>Vomiting.</p> </Section> <Section>History of Present Illness <p>Diarrhoea and vomiting for last 4 days. Not eating much and so didn't think she needed to take insulin. Known type 1 diabetic since 2014.</p><br /> <p>Diarrhoea now settled but vomiting and abdominal pain ongoing. Feels very fatigued, drowsy and unwell.</p> </Section> <Section>Assessment <p>Diagnosis: DKA<br /> Examination: Dry mucous membranes, decreased skin turgor, dry tongue - appears dehydrated.<br /> Investigations: Blood glucose > 250mg/dL, Ketones > 3mmol/L, pH 7.27.</p> </Section> <Section>Plan of care <p>Immediate fluid replacement as per standard DKA pathway - start 0.9% Sodium Chloride<br /> Fixed rate Actrapid insulin infusion at 5 units/hour initially<br /> Hourly venous blood gas<br /> Review clinical condition every 1 hour at a minimum<br /> Consider stepping down treatment once ketosis has resolved<br /> Will need re-assessment upon discharge for long term insulin plan.</p> </Section> </Note>

Context graph

Structured data

Patient
  • Name: Matilda Wormwood
  • Address: 15811 Youngwood Dr, Whittier, CA, USA
  • Telephone: (781)556-9873
Demographics
  • DOB: 1 October 1988
  • Sex: F
  • Marital status: S
  • Ethnicity: Caucasian
Provider
  • Name: CareMore Medical Group
  • Address: 9209 Colima Rd, Whittier, CA 90605
  • Telephone: 562-236-2290
  • Informant: Raymond Gonzo
Plan
  • Payer: Kaiser-Permanente
  • Policy: Bronze 65 HMO
  • MemberID: ABC123456789

Unstructured data

Reason for referral Suspected Diabetic Ketoacidosis (DKA) Chief complaint Vomiting. History of Present Illness Diarrhoea and vomiting for last 4 days. Not eating much and so didn't think she needed to take insulin. Known type 1 diabetic since 2014. Diarrhoea now settled but vomiting and abdominal pain ongoing. Feels very fatigued, drowsy and unwell. Assessment Diagnosis: DKA Examination: Dry mucous membranes, decreased skin turgor, dry tongue - appears dehydrated. Investigations: Blood glucose > 250mg/dL, Ketones > 3mmol/L, pH 7.27. Plan of care Immediate fluid replacement as per standard DKA pathway - start 0.9% Sodium Chloride Fixed rate Actrapid insulin infusion at 5 units/hour initially Hourly venous blood gas Review clinical condition every 1 hour at a minimum Consider stepping down treatment once ketosis has resolved Will need re-assessment upon discharge for long term insulin plan.