48M with diabetic ketoacidosis

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