22 years old male with diabetic ketoacidosis

M Kalpana

9th sem

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

I’ve 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

Case:

22 years old male came to hospital on 16/10/21 with complaints of

-fever with chills since 1 day

-dry cough since 1day

-cold since 1day

-SOB since afternoon

history of presenting illness:

patient was apparently asymptomatic 12years back then he had SOB and vomitings  where he came to our hospital  ,was diagnosed to be diabetes Mellitus type-1, from then he is taking insulin of 20U &10U bd but from past 2years he is taking only once 20U at mrng and now presented with SOB with GRBS 509mg/dl

from past 12 years he visited to hospital 5/6 times for similar complaints 

he gave history of not taking insulin(missed insulin)dose

Past history :

k/c/o DM type 1 since 12 years &was taking insulin injections

personal history:

diet - mixed

appetite- decreased

bowel& bladder- regular

sleep- adequate

no allergies & addictions

general examination:

patient was conscious ,cooperative & coherent

well oriented to time , place , person 

moderately built and moderately nourished

pallor- present 

icterus-absent 

clubbing-absent

cyanosis-absent

Lymphadenopathy-absent

edema-absent

Vitals:

temp-afebrile

pulse rate-98 /minute

resp rate-32 cpm

BP-110/80mm Hg 

spo2-99%

GRBS-509 mg/dl

Systemic examination:

RS- BAE

    Normal vesicular breath sounds heard 

CVS- S1,S2

Per abd- soft &non tender

CNS- NAD

Investigations:

USG-

---

On 18/10/21

Referred to ENT -

Refered to ophthalmology-

Provisional diagnosis:

Diabetic ketoacidosis [ DM type-1] secondary to missed insulin dose

treatment:

On 16/10/21

 NBM until further orders

IVF-NS RL— 150 ml/hr continuous infusion

inj.H.A.I infusion @4ml/hr- 1ml of HAI in 39 ml NS

inj.pantop 40 mgIV OD 

GRBS charting hourly

tab dolo 650 mg sos

strict I/O charting

vitals monitoring

17/10/21

Inj. Human ACTRAPID  sc TID @ 4ml/hr- 1 ml of H .A.I in 39 ml of NS

inj. Ceftrioxne 1gm IV bd

syp ascoryl 5ml-x-5ml

inj.pantop 40mg/IV /OD

inj.MVT/1 amp in NS /IV/OD

IV fluids [NS RL 5D]

GRBS monitoring every hourly

ABG & electrolytes 12hrly

18/10/21

19/10/21