30 year old Male with DKA

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CASE : 

A 30 year old male patient resident of suryapet and a watchmen by occupation came to casualty with C/O 

• Loose stools since yesterday morning
• vomitings since yesterday morning 
• shortness of breath since yesterday evening. 

HOPI : 

--- Patient was apparently asymptomatic till yesterday morning then he developed

• vomitings which are non bilious, non projectile, non blood tinged filled with food particles(10 episodes since yesterday which subsided from today morning). 
• C/o loose stools 2 episodes yesterday morning which are watery, non blood tinged,non mucopurulent,not associated with fever, pain abdomen. 
• C/o shortness of breath (grade 3) from yesterday evening which is not associated with chest pain, palpitations, orthopnea, pnd. 

--- Patient was admitted in Gandhi hospital yesterday evening and was 

given IV fluids and Inj.HAI 40IU.

--- Patient then came to our hospital due to shortness of breath.

Past history :

• K/C/O DM since 4 years(was on insulin mixtard 10u-X-10u and was shifted to Tab.Metformin 500). 
• H/O Pulmonary TB 4 years ago (used ATT for 6 months)Tab. Glipizide 5 mg PO/BD from 1 week). 
• H/O Pulmonary effusion(ICD was present for 10-15 days.
• Not a K/C/O HTN, CVA, epilepsy, thyroid disorders.

Personal history :

• Diet-mixed 
• Appetite-normal 
• Sleep-adequate 
• Bowel and bladder movements-regular  
• Addictions : 90 ml whiskey thrice daily

Routine history :

---Patient used to do construction work 4 years back then one day he had fever and increased urinary frequency and was lethargic so went to a local rmp and diagnosed to have diabetes, so he stopped doing construction work as he thought he might have injuries and may not heal. 

---He didn't go to any work for 5 to 6 months because of fatigue and cough and diagnosed with TB ( he used 6 months mediation and was complient). 

---Now he is working as watchman.

Current daily routine :

---He wakes up at 6 am and takes 10U of HAI and has breakfast and goes to work and has lunch at 2pm and then goes around for a walking if he feels bloated and takes 10U of HAI before having dinner at 8 pm and sleeps at 10pm.

General examination :

---Patient is conscious, coherent and cooperative He is moderately built and moderately nourished.

---No signs of icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals :

• Temp: 98.7F
• PR- 106 bpm
• RR-23cpm
• BP-130/70 mm of Hg
• Spo2 - 98%
• GRBS:130mg/dl

Systemic examination :

• CVS - S1, S2 heard, no murmurs
• RS - BAE +, NVBS heard
• PA - Soft, non tender
• CNS - NAD

Provisional diagnosis :

--- Diabetic ketoacidosis with K/C/O Diabetes since 4 years and Pulmonary TB 4 years ago. 

Investigations :

Hemogram - 

On 15-07-23

Hb - 14.7 mg/dl

TLC - 16,300 cells/mm3

Platelets - 2.03 lakhs

On 16-07-23

Hb - 14.8 mg/dl

TLC - 7,900 cells/mm3

Platelets - 1.50 lakhs

RBS - 224mg

HBA1C - 6.8gm%

CUE - 

Albumin - 2+

Sugars - 3+

RBC - NIL

Pus cells - 2-3 cells

Epithelial cells - 3-4 cells

Urine for ketone bodies - positive

LFT :

TB - 6.70

DB - 0.32

AST - 13

ALT - 12

ALP - 245

TP - 6.9

Albumin - 4.38

A/G - 1.74

S. Creat - 0.8

Blood Urea - 44

Serum electrolytes :

On 15-07-23

Na+ - 139

K+ - 4.6

Cl- - 102

Ca+2 - 1.22

On 16-07-23

Na+ - 136

K+ - 4.1

Cl- - 101

Ca+2 - 1.23

ABG :

On 15-07-23 4:15pm

pH - 7.11

pCo2 - 6.3

pO2 - 118

HCo3 - 2.0

On 15-07-23 11:30pm

pH - 7.28

pCo2 - 23.3

pO2 - 114

HCo3 - 10.8

On 16-07-23 5:20am

pH - 7.34

pCo2 - 26.2

pO2 - 120

HCo3 - 16.8

Treatment :

On 15-07-23

S:

Vomitings have subsided. Patient has slight shortness of breath.

O:

Patient is c/c/c

Temp : 98.7F

PR - 96bpm

RR - 18cpm

BP - 110/80 mmHg

Spo2 - 98%

GRBS : 273 mg/dl

RS - BAE +, NVBS

CVS - S1,S2 present, no murmurs.

PA - soft, non tender 

CNS - NAD

A:

Diabetic ketoacidosis(resolved) secondary to non compliance K/c/o DM type 1 since 4 years

P:

1. Inj.NPH S/C BD premeal (12u—12u)

2. Inj. HAI S/C TID premeal (14u——14u——14u)

3. Grbs 7 point monitoring 

4. Syp. Potklor PO/TID 10 ml

5. Monitor vitals fourth hourly

On 16-07-23

S:

One fever spike +, Shortness of breath has reduced,

O:

Patient is c/c/c

Temp : 99.2F

PR - 90bpm

RR - 17cpm

BP - 120/80 mm of Hg

Spo2 - 99%

GRBS : 198 mg/dl

RS - BAE +, NVBS

CVS - S1,S2 present, no murmurs.

PA - soft, non tender 

CNS - NAD

A:

Diabetic ketoacidosis(resolved) secondary to non compliance K/c/o DM type 1 since 4 years

P:

1. Inj.NPH S/C BD premeal (12u—12u)

2. Inj. HAI S/C TID premeal (14u——14u——14u)

3. Grbs 7 point monitoring 

4. Syp. Potklor PO/TID 10 ml

5. Monitor vitals fourth hourly

On 17-07-23

S:

No fever spikes. Patient is feeling better and hungry.

O:

Patient is c/c/c

Temp : 98.2F

PR - 94bpm

RR - 18cpm

BP - 120/80 mm of Hg

Spo2 - 99%

GRBS : 179 mg/dl

RS - BAE +, NVBS

CVS - S1,S2 present, no murmurs.

PA - soft, non tender 

CNS - NAD

A:

Diabetic ketoacidosis(resolved) secondary to non compliance K/c/o DM type 1 since 4 years

P:

1. Inj.NPH S/C BD premeal (12u—12u)

2. Inj. HAI S/C TID premeal (14u——14u——14u)

3. Grbs 7 point monitoring 

4. Syp. Potklor PO/TID 10 ml

5. Monitor vitals fourth hourly