DIABETIC KETOACIDOSIS WITH DENOVO DETECTED DM WITH VIRAL PYREXIA UNDER EVALUATION

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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 plan.

UNIT 5 ADMISSION: 

A 21year old male resident of miryalaguda came to the casualty with

Chief complaints:-

Fever since 5 days, decreased appetite since 7days, vomiting  since 1day, sob since morning.

History of presenting illness:-

Patient was apparently asymptomatic 5days back then he developed fever which is of incidious in onset, intermittent and is of high  grade fever,a/w chills and relieved on medication.  Pt has H/o  1episode of vomiting 1day back which is non bilious,non projectile.

No h/o any burning micturition,throat pain,cold,cough.

PAST HISTORY:-

Not a k/c/o HTN,DM, CAD, asthma, TB, epilepsy.

PERSONAL HISTORY:-

Patient has mixed diet with normal appetite and adequate sleep. 

he has normal bowel movements and bladder filling. 

No addictions. 

No significant family history or allergic history. 

GENERAL EXAMNATION:-

Patient is c/c/c with moderate built and moderate nourishment. 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 

VITALS:

BP: 140/90 MMHG, 

PR: 120bpm 

Temp: 98.2°F, 

RR: 40 CPM, 

SPO2: 99% 

Systemic examination:-

RS: BAE+,NVBS

CVS: S1 ans S2 heard. No murmurs. 

P/A: soft and non-tender. 

CNS: No focal deformities. 

INVESTIGATIONS:-

1) HEMOGRAM : 

Hb: 8.2

TLC: 15800

N:89

L:6

PCV: 30

Mcv:63.7

MCH:17.4

MCHC:27.3

PLC:3.37

RBC:4.71

2) LFT:

3)CUE

4)RBS:194 

5)BLOOD UREA:29

6)SERUM CREATININE:0.8 

7)URINE FOR KETONE BODIES:

8)ABG@2PM 

9)SERUM ELECTROLYTES @2pm

S.ELECTROLYTES@ 10PM 

10) Chest xray PA view: 

PROVISIONAL DIAGNOSIS:DIABETIC KETOACIDOSIS WITH DENOVO DETECTED DIABETES MELLITUS WITH VIRAL PYREXIA UNDER EVALUATION

TREATMENT: 

On DAY-1

1)NBM till further orders

2)IVF 3lit NS  @500ml/hr(in 3hrs) f/by IVF NS@250ml/hr 

3)Inj. HAI 4IU IV/stat f/b Inj. HAI 1ml (40IU) in 49ml NS @ 4ml/hr(untill ABG correction)

4)Inj. PAN 40mg IV/OD

5)IVF 5%DEXTROSE @50-100ml/hr(when GRBS <150) [increase/decrease acc. to GRBS]

6)Inj.OPTINEURON 1amp in 100ml NS/IV/OD 

7)GRBS monitoring hourly

8) Strict i/o. Monitoring

9)Inj. KCl 2amp in 500ml NS @100ml/hr

On DAY-2 :

SOAP NOTES:

S: 

No fever spikes,sob decreased ,no fresh complaints

O:

BP-110/90mm hg

PR-74bpm

CVS:S1S2 heard

Rs:BAE +,NVBS

P/A:soft

A:

HAGMA, DKA

Hemogram:

ABG @1AM

@8AM

@3PM

S.ELECTROLYTES:@8AM

@5PM

@10.30PM

P:

1)IVF 0.45% NaCl,RL @100ml/hr 

2)Inj. KCl 2amp in 500ml NS @100ml/hr

3)Inj. HAI 1ml (40IU) in 39ml NS @ 4ml/hr(untill correction of acidosis)

4)Inj. PAN 40mg IV/OD

5)Inj.OPTINEURON 1amp in 100ml NS/IV/OD 

6)GRBS monitoring hourly

7)Strict i/o. Monitoring

8)NBM till further orders

DAY-3 :

S: Patient sob decreased,No fresh complaints

O: BP 110/80 mm hg

PR: 70 bpm

CVS: s1 s2 heard 

RS: BAE+ NVBS 

P/A: soft 

S.ELECTROLYTES @8AM

Assesmemt : over night patient grbs around 290 mg/dl and Patient anion gap is reducing day by day and subjectively feeling better .

Plan : Look for today morning abg and stop iv insulin infusion and start him on NPH and HAI