48M with diabetic ketoacidosis

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Hi!! This is Vijaya ratna 9th semester medical student.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 


A 48 year old male Patient lorry driver by occupation came to general medicine department with c/o 
Dragging type of pain in both upper and  lower limbs since 1 week
Generalized weakness since 4 days
Fever since 1 day

HOPI
patient was apparently asymptomatic 1week back then had dragging type of pain in upper and lower limbs since 1 week which is continuous,aggravated on working with no relieving factors associated with generalized weakness
C/o fever since 1 day intermittent in onset,high grade,not associated with chills and rigors,more during night,no aggravating factors and relieved on medication.
No c/o cough,cold,sore throat
No c/o headache
No c/o burning micturition 

Past History
K/c/o DM type II since 5 years 
N/K/c/o hypertension,CAD,TB,asthma,epilepsy 
No similar complaints in the past

Personal History
Mixed diet
Normal Appetite
Regular bowel and bladder movements
Sleep - adequate
Addictions
H/o Alcohol intake for 20 years,stopped 5years back
H/o smoking beedis for 20 years,stopped 5 years back

Treatment History 
Drug History
Tab.voglibose 0.2mg 
Tab.Gliclazide 40mg 
Tab.Metformin 500mg PO/OD for diabetes since 5 years

Family History
No significant family history

GENERAL EXAMINATION
patient is conscious,coherent and cooperative 
Moderately built and malnourished 
Pallor present
No signs of icterus,cyanosis,clubbing,edema of feet and lymphadenopathy 
Mid arm circumference - 26cm/260mm
Triceps skinfold thickness - 11mm
Abdominal girth - 88cm/880mm
MAMC - 260 - 3.14*11mm = 225.9 mm
Visceral fat - 880/225.9 =3.89

VITALS
temperature - 100.8F
Pulse rate - 80bpm
BP - 100/ 60 mmHg
RR  - 18 cpm
GRBS - 393 mg/dl

SYSTEMIC EXAMINATION 
CARDIOVASCULAR SYSTEM 
S1,S2 heard,no murmurs,no thrills

RESPIRATORY SYSTEM 
position of trachea - central
Normal vesicular breath  sounds 
No dyspnea and wheeze

PER ABDOMEN
Shape of abdomen - scaphoid

Umbilicus is central in position
No Tenderness on Palpation
Temperature - High
Liver is non palpable 
Spleen is non palpable 
Bowel sounds heard

CNS - NFND


INVESTIGATIONS 

25/10/23
RBS - 461mg/dl
Blood urea - 32mg/dl
Albumin - nil
Pus cells - 2-3
Epithelial cells - 1-2
Serum creatinine - 0.9
Na - 136mEq/L
K - 3.9 mEq/L
Cl - 101mEq/L
Ca- 1.04mg/dl
Hb - 14.1gm/dl
TLC - 4300 cells/cumm
PCV - 38 vol%
platelets- 1.50lakhs/cumm
HbA1C - 7.5

26/10/23
Na - 135mEq/L
K - 3.5 mEq/L
Cl- 99mEq/L
Ca - 1.10 mg/dl
Hb - 12.2gm/dl
TLC - 11300 cells/cumm
PCV - 32.5 vol%
Platelets - 2.70 lakhs/cumm

27/10/2023
Hb - 12.3gm/dl
TLC - 6400cells/cumm
platelets - 2.08 lakhs/cumm
Na - 130mEq/L
K - 4.4 mEq/L
Cl - 96 mEq/L
Ca - 1.09mg/dl

ABG analysis
pH - 7.32
pCO2 - 32.7mmHg
pO2 - 45.7 mmHg
HCO3 - 16.4mEq/L

ABG



ECG

2D ECHO
27/10/2023
PROVISIONAL DIAGNOSIS
DIABETIC KETOACIDOSIS with pyrexia under evaluation k/c/o DM II since 5 years

TREATMENT
25/10/23
Inj.Human actrapid insulin 6 units IV/ Stat 
          1ml insulin [HAI] 6units stat
IV fluids NS @ 100ml/hr
IV fluids 5% dextrose - to maintain dextrose
Tab.Dolo 650mg PO/TID
Monitor GRBS hourly
Monitor Vitals hourly

26/10/23
Inj Monocef 1gm IV/BD
Inj.Human actrapid insulin 6 units IV/ Stat 
          1ml insulin [HAI] + 39ml NS
Inj.Dextrose IV
IV fluids NS @ 100ml/hr
Monitor Vitals hourly
Inj.H actrapid
Inj.NPH insulin

27/10/23
Inj Monocef 1gm IV/BD
IV fluids NS @ 100ml/hr
Inj.Human actrapid insulin TID
Inj.NPH insulin sc SOS acc to GRBS
Inj.Pan 40mg IV/OD/BBF
Inj Neomol 1 gm IV/SOS if temp is 101F
Monitor GRBS
Monitor vitals



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