Diabetic ketoacidosis
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Patient came to casualty with
C/O:1) Shortness of breath since afternoon
2)Fever since afternoon
3)Rash over the abdomen since 3 days
HOPI:
Patient was apparently asymptomatic 2 hours ago then she developed SOB, sudden in onset, grade - 4. No orthopnea and PND.
No H/O chest pain, Pedal edema, palpitations, excessive sweating, giddiness and wheeze
Fever since 8 hours, high grade, a/w chills and rigor since 2 pm afternoon
Rash over the abdomen since 3 days, no itching or redness, watery discharge. Applied crushed paracetamol tablet on the rash
No H/O , loose stools, pain abdomen, giddiness.
Dialy routine of patient :
Wakes up at 6 am in the morning
Takes insulin at 7:15 am( 4 units of isophane and 6 units of HAI) and eats breakfast at 7:40 am
Starts to school at 7:50 am (travels via grandfather's bike)
Has Lunch at 12:30 pm
Comes home at 5 pm and eats snacks
Goes to tution from 5 - 8 pm
Takes insulin at 8:15 pm (4 units of isophane and 6 units of HAI) and eats at around 8:40 pm
Sleeps at around 10 pm
Events on 13-07-23 :
Woke up at 7 am
Missed the morning dose of insulin and breakfast because she was late to school
Went to school at 8 am
Felt giddiness and told the Teacher about it. Teacher asked her to eat.
Refused to eat due to nausea
Had Vomiting at 11 pm - water content
At 12:30 vomited once again - water content
Informed her grandfather and went home at 1 pm
At home she started developing SOB so didn't eat again
Went to local doctor due to SOB at 5 pm
She was put on O2 there and when it didn't resolve the doctor advice to go to higher centre
Came to kamineni at 7:30 pm
Past history :
Patient is known case of Type 1 DM since 3 yrs.
Diagnosed 3 yrs before when she complained of polyuria.
After diagnosis she used to take 4+4 HAI and Isophane in the morning and night. And 2+2 HAI and isophane in the afternoon.
After one year, on a regular checkup, her sugars weren't controlled, So she was advice to take HAI - 6 IU, Isophane - 4 IU 20 mins before eating since 2 years .
H/O right humerus fracture 1 year back (skid and fall from bike while going to school). Treated conservatively with cast for 1 month
Family history : H/O Type 1 DM in father. Diagnosed at 12 years. Was on insulin treatment.
Father was on dialysis due to CKD 7 yrs back and died 5 years back
General examination :
No signs of pallor, icterus, cyanosis, clubbing, Lymphadenopathy and pedal edema
Vitals on admission :
PR : 158 bpm
BP : 110/60 mmhg
TEMPERATURE : 98.6 F
RR : 54 cpm
Spo2 : 98% on RA
GRBS : High
Systemic examination :
RESPIRATORY SYSTEM EXAMINATION :
Bilateral air entry +
Normal vesicular breath sounds
Trachea central
No added sounds
CVS EXAMINATION :
S1, S2 heard
No murmurs
ABDOMEN EXAMINATION :
No tenderness
No organomegaly
Bowel sounds - present
Rash on the abdomen
CNS EXAMINATION :
Gcs - E4V5M6 (15/15)
Higher mental functions - normal
Cranial nerve examination - normal
Sensory and motor system normal
No signs of meningeal irritation
Investigations :
URINE FOR KETONE BODIES : positive
RANDOM BLOOD SUGAR : 624 mg/dl
HEMOGRAM :
RFT:
LFT :
Diagnosis : Diabetic ketoacidosis with type 1 DM
Treatment :
1) IV fluids 40 ml bolus followed by NS 150 ml/hr
2)INJ HAI - 8 IU / stat
3)Inj HAI 40 IU in 39 ml NS @ 6 ml / hr (Inc/Dec according to GRBS)
4)IV fluids - 5D @ 50 ml/hr if GRBS < 200 mg / dl
5)Input / Output charting
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