35 yr old with dka

 This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan.

Complaints of shortness of breath since two days on and off increased since morning

 complains of fever since two days

 complains of burning micturition since two days

HOPI

Patient was apparently a symptomatic five years back then he was diagnosed with diabetes mellitus for which he was started on oral hypoglycaemic drugs later was advised insulin after two years of usage of oral hypoglycaemic agents patient had similar episode 15 days back and got admitted at private hospital and was on unknown medication following missing insulin  for two days 

history of DKA 1 yr ago  admitted in our hospital

Patient complains of SOB since two days ,(progressed to grade 4 today morning)not associated with cough ,cold ,chest pain ,Giddiness

 complains of fever, high-grade not associated with chills since two days associated with burning maturation not associated with vomiting ,loose stools, history of missing insulin dosage and  not eating since two days due to work stress nonavailability of insulin 

Patient is Known case of diabetes since seven years on isophane insulin 25 units

 history of recurrent Dka  15 days back and one year back

N/K/C/O HTN,BA,TB,CVD

GENERAL EXAMINATION 

Patient is Conscious, coherent,co operative well oriented to Time,place,person

No pallor, No icterus, No Cyanosis, No Lymphadenopathy, No Edema

VITALS

Temperature -98F

Pulse rate- 98bpm

Blood pressure-140/90mm hg

Respiratory rate -20cpm

SYSTEMATIC EXAMINATION:

PER ABDOMEN:Soft, non tender

No guarding, No rigidity 

Bowel sounds present 

CARDIOVASCULAR SYSTEM:

S1,S2 heard, NO Murmurs 

RESPIRATORY SYSTEM:

BAE present,NVBS

CENTRAL NERVOUS SYSTEM:

NAD

PROVISIONAL DIAGNOSIS-DKA

INVESTIGATIONS 

Hb-14

Tlc-23000

Rbc-4.82

Blood urea-32mg/dl

TB-1.31

DB-0.56

SGOT-14

SGPT-10

ALp-261

TP-6.6

Alb-4.42

A/G-2.03

S creatinine-1

Na-142

K-4

Cl-103

Urine ketones-positive

GRBS

26/5/22

2am-222mg/dl

8am-324mg/dl - HAI 15U

10am-287mg/dl

12pm-253mg/dl- HAI 15U

2pm-220mg/dl

8pm-100 mg/dl -4 N +8 A

10pm-197mg/dl

27/5/22

2am-166mg/dl

8am-260mg/dl-6NPH+10HAI

Treatment 

1.INJ PAN 40MG IV

2.INJ MONOCEF 1gm IV BD

3.IVFNS 3,RL 1 @150ml/hr continuous

4.INJ HAI S/c 14 U STAT

5.INJ HUMAN ACTRAPID INSULIN INFUSION

(1unit in 39ml NS )@ 6mp/hr

6.START 5% D INFUSION @100ml/hr if GRBS <200mg/hr

7.maintain GRBS 150-200mg/hr

8.INJ NAHCO3 50 meq IV /stat f/b  150meq in 1.NS @ 250ml/hr

9.INJ ONDEM 4mg SOS

10.GRBS MONITORING HOURL

11.4th HOURLY TEMP CHARTING

26/5/22

1.IVF NS,RL@100ml/ht

2.INJ MONOCEF 1gm IV BD

3.INJ KCL 1 amp in 100 ml NS over 4-5 hrs

4.INJ PAN 40MG IV OD

5.INJ ZOFER 4mg IV SOS

6.INJ NEOMOL 1gm IV SOS(if temp >101F)

7.INJ HAI /SC 

8.TAB DOLO 650mg PO TID

9.7 Point profile monitoring