32M with DKA K/C/O DM since 4 years Pulmonary TB 4 years ago
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Cheif Complaints :
32 year old male Who is Resident of Munagala ( Suryapet District ) with Educational qualification 7th class Who is a Watchman by Occupation Presented to Casualty With Chief Complaints of
Vomitings Since Yesterday Morning ( 14/7/23 )
SOB Since Yesterday Evening ( 14/7/23 )
HOPI :
From the Age of 20 Years He used to work as Mason ( Centring Work ) During That Time His Routine Was :
Wakes Up at 6am ; Freshup , Have Breakfast by 8:30am ; goes to work by 9am ; Does Centring Work at Construction Site Till 1PM & Has Lunch ; Continue the Same Work till 5 PM after work he goes out with his co workers for Drinking alcohol after that he goes to Home by 8PM ; after Having Dinner Sleeps by 10PM.
Alcohol Habbit :
Intially It Started due to His Co Workers & Later Turned into Habbit & Consumes Daily 90-180ml
History of diabetes: ( 2019 )
4 years ago Pt has history of polyuria and fatigue for which he went to a local doctor and was diagnosed diabetes and was kept on OHA but he continued to have Polyuria & fatigue for which he went to the doctor after a week and was switched to insulin (MIXTARD) 10U BD & Continue to Work as Mason & Stopped Drinking Alcohol For around 1 Month & Took Insulin Regularly. After 1 Month as His Symptoms are Resolved He Thought He was dng Good & Started Talking Alcohol After His Work Along With his Co-workers & Missed Taking Insulin
2019 :
4 months later he had fever, cough, SOB then he went to area hospital in Suryapet , an Xray was taken and told to have Fluid Around Lungs ( Pleural Effusion ) was advised to take him to our hospital. In Our Hospital He was diagnosed with Tuberculosis and Started ATT ; ICD Was Placed on right side of chest in V/O Pleural Effusion & ATT Was Continued For 6 Months. After 6 months He Along with His wife & Children were tested for TB which turned out to be Negetive.
After These Events He Stopped Going to Work & Stayed at Home Only. So Stopped Alcohol & Took Insulin Regularly. ( During This time His Family Was Financially Supported his Sisters )
2022 :
1 Year Ago Their Family Was Shifted to Hyderabad ( Mothinagar ) Where he Started a New Job as Watch Man To Apartment ( Earns 9000/Month ) & His Wife Works as Maid in that Apartment ( Earns Around 4000/Month ) & His 2 Children Goes to Government School. There His Daily Routine Was Like
Walks Up at 6am ; Cleans the Cars in Apartment ; Freshup by 8AM ; Brings Groceries to Some Families in the Apartment ; Has his Breakfast Which Contains Rice & Curry After Taking Insulin & Most Of His Worktime Would Involve Sitting in Front of Gate & Has his Lunch at 2PM Which Contains Rice & Curry & Sleeps For About 1 Hour ; Then Continues to Sit in Front of Gate Till Night. Then He Has Dinner at around 9PM Which Contains Rice & Curry after Taking Insulin ; Sleeps Around 10PM.
He Drinks Alcohol Once in 3 Days in His Home & Some Times Takes Biryani From Outside When he Drinks Alcohol. He Skips Insulin Whenever He Takes Alcohol. He Never Checked His Sugar Levels.
From the Past 10days he has been working as an office boy in a Small office near his apartment where he cleans the computers & Room and serves tea in the morning and evening and sits most of the time in the day
His Watchman Works were managed by his wife from these past 10days
1 week ago when the pt was asked to Cut a Small Weed Plant near Apartment by One of the Flat Owners then patient informed to him that he would want to wear his footwear as he is diabetic, for which employer asked about his medication for diabetes and by knowing he is on insulin, Flat Owner checked his GRBS by the Glucometer Which Was Used by his Wife ( Who is also a Diabetic & On OHAs ) and it was 420mg/dl after Breakfast So the Flat Owner Asked him to Take OHAs Which His Wife Was Using ( T.GLIPIZIDE 5MG + METFORMIN 500MG PO BD ) & Stop Insulin Then Patient Stopped Insulin & Started Above Medication & the Next Day GRBS Was 360mg/dl after Breakfast. As there Was Decrease in GRBS From 420 to 360 The flat owner asked him to Continue Same Medication & Informed him that He Will Check his GRBS After 1 week.So he Continued to take OHAs & Took Rice for 3 times.
On Wednesday night (12/7/23 night ) Patient travelled to his hometown for a function Where he Took Alcohol & Had Food in the Function & Skipped Night Medication. On Thursday ( 13/7/23 ) he again took alcohol and skipped medication and went back to Hyd.Then on Friday ( 14/7/23 ) Morning he started having vomitings for About 10 Episodes on That Day & Started Having SOB for which he was taken to a local hospital where he was given IV Fluids but the Condition did not Resolve then the next morning ( 15/7/23 ) he was taken to Gandhi hospital in Hyd and Was Diagnosed to Have DKA & Started Treatment But His SOB did not Resolve so they Thought to Come to Our Hospital as they Were Admitted in Our Hospital Previously got Cured so came here on Saturday Evening & Got Admitted
Family History:
Married at the age of 22years.
He has 2 siblings (sisters)
He has 2 kids (studying 5th and 2nd class)
His Wife Complains that He won't listen to Her advice to Stop Alcohol & Take Insulin Regularly
General examination:
Patient is conscious, coherent and cooperative He is thin built and moderately nourished
No signs of Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema
Vitals at Presentation :
Patient is conscious,coherent, cooperative & well oriented to time place person
BP-100/70 mm of Hg
PR - 142bpm
RR - 44cpm
Temp-98.7F
Spo2 - 98% on Room Air
GRBS - 246mg/dl
Systemic examination:
PER ABDOMEN
Inspection:
No Abdominal distension
No scars, sinuses, mass visible
Palpation:
Inspectory findings are confirmed
No local rise of temperature
No Tenderness present
Auscultation:
Normal bowel sounds heard
RESPIRATORY SYSTEM EXAMINATION
Inspection:
Bilaterally Symmetrical chest movements present
No scars and sinuses
Trachea central
Palpation:
Inspectory findings are confirmed
Percussion:
Resonant note present in all lung areas
Auscultation:
Normal vesicular breath sounds heard.
CARDIOVASCULAR SYSTEM EXAMINATION
Inspection :
Bilaterally symmetrical chest present
No scars, sinuses
Palpation:
Inspectory findings are confirmed
Apex beat is in left 5th ICS half inch Medial to Midclavicular Line
On Auscultation :
S1 S2 heard, no murmurs or additional heart sounds
CENTRAL NERVOUS SYSTEM EXAMINATION
Higher mental functions intact
Cranial nerves intact
No focal neurological defecits
Provisional diagnosis :
1.DIABETIC KETOACIDOSIS SECONDARY TO NON COMPLIANCE
2. K/C/O DIABETES SINCE 4 YEARS and PULMONARY TB 4 YEARS BACK ( RESOLVED)
Investigations:
GRBS TRENDS :
15/7/2023
7pm 216mg/dl
8pm 180mg/dl
9pm 195mg/dl
10pm 209mg/dl
16/7/2023
12am 192mg/dl yy
1am 196mg/dl
2am 168mg/dl
3am 157mg/dl
5am 153mg/dl
6am 132mg/dl
7am 130mg/dl
8am 112mg/dl
10am 116mg/dl
12pm 126mg/dl
2pm 128mg/dl
4pm 135mg/dl
6pm 142mg/dl
8pm 252mg/dl
10pm 295mg/dl
17/7/23
12am 185mg/dl
2am 194mg/dl
4am 220mg/dl
6am 179mg/dl
8am 170mg/dl
Treatment:
16/7/23
1.IV Fluids NS @250 ml/hr
2.Inj.Hai 40u in 39 ml NS Infusion according to GRBS
3.Inj.5%Dextrose @100 ml/hr If GRBS < 150mg/dl
4.Monitor grbs hourly
5.Monitor vitals second hourly
6.strict I/O charting
17/7/23
1.Inj.NPH s/c BD premeal according to GRBS
2.Inj.HAI s/c TID premeal according to GRBS
3.GRBS 7 Point profile monitoring
4.Monitor vitals fourth hourly
5.strict I/O charting
Discussion:
Complexity Issues :
1. Alcohol
2. Eating Food with High Carbohydrates all 3 Times
3. No Physical Activity
4. No Follow Up for Diabetes
There is more in his life events
1. Socioeconomic status
2. Alcohol
3. Type 1 diabetes 2019 (unrelated to alcohol or type 3)?
4. Socio economic burden of both Diabetes and TB in 2019 having to give up work and dependent on sisters
5. Misinformation from offline social circle
6.Emergency hospital access separated by wide distances
PaJR Group Link :
https://chat.whatsapp.com/F1Pz67MzYHHFWdDlyj9E2Y
Discharge Summary:
Diagnosis
DIABETIC KETOACIDOSIS (RESOLVED ) SECOUNDARY TO NON COMPLIANCE .
Case History and Clinical Findings
CHIEF COMPLAINTS:
LOOSE STOOLS AND VOMITINGS SINCE YESTERDAY MORNING AND SHORTNESS OF BREATH SINCE YESTERDAY EVENING.
HISTORY OF PRESENTING ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC TILL YESTERDAY MORNING THEN HE DEVELOPED VOMITINGS WHICH ARE NON BILIOUS, NON PROJECTILE, NON BLOOD TINGED FILLED WITH FOOD PARTICLES(10 EPISODES SINCE YESTERDAY WHICH SUBSIDED FROM TODAY MORNING). C/O LOOSE STOOLS 2 EPISODES YESTERDAY MORNING WHICH ARE WATERY, NON BLOOD TINGED,NON MUCOPURULENT,NOT ASSOCIATED WITH FEVER, PAIN ABDOMEN. C/O SHORTNESS OF BREATH (GRADE 3) FROM YESTERDAY EVENING WHICH IS NOT ASSOCIATED WITH CHEST PAIN, PALPITATIONS, ORTHOPNEA, PND.
STOPPED INSULIN ON 4TH JULY AND STARTED WITH ORAL HYPOGLYCEMIC SINCE 10DAYS.
PAST HISTORY:
HE IS A K/C/O DM SINCE 4 YEARS(WAS ON INSULIN MIXTARD 10U-X-10U AND WAS SHIFTED TO TAB.METFORMIN 500). HE ALSO HAS H/O PULMONARY TB 4 YEARS AGO (USED ATT FOR 6 MONTHS)TAB. GLIPIZIDE 5 MG PO/BD FROM 1 WEEK). H/O PULMONARY EFFUSION(ICD WAS PRESENT FOR 10-15 DAYS
NOT A K/C/O HTN CAD CVA ASTHMA EPILEPSY THYROID DISORDERS.
PERSONAL HISTORY:
DIET-MIXED
APPETITE-NORMAL
SLEEP-ADEQUATE
BOWEL AND BLADDER MOVEMENTS-REGULAR
ADDICTIONS:90 ML WHISKEY THRICE DAILY SINCE 15 YEARS
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE HE IS MODERATELY BUILT AND MODERATELY NOURISHED
NO SIGNS OF ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA
VITALS:
PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE.
TEMP: 98.7F
PR- 106 BPM
RR-23CPM
BP-130/70 MM OF HG
SPO2 - 98%
GRBS:254MG/DL
SYSTEMIC EXAMINATION:
PER ABDOMEN
INSPECTION:
ABDOMINAL -SCAPHOID
NO SCARS, SINUSES, MASS VISIBLE
PALPATION:
INSPECTORY FINDINGS ARE CONFIRMED
NO LOCAL RISE OF TEMPERATURE
NO TENDERNESS PRESENT
AUSCULTATION:
NORMAL BOWEL SOUNDS HEARD
RESPIRATORY SYSTEM EXAMINATION
INSPECTION:
BILATERALLY SYMMETRICAL CHEST MOVEMENTS PRESENT
NO SCARS AND SINUSES
TRACHEA CENTRAL
PALPATION:
INSPECTORY FINDINGS ARE CONFIRMED
PERCUSSION:
RESONANT NOTE PRESENT IN ALL LUNG AREAS
AUSCULTATION:
NORMAL VESICULAR BREATH SOUNDS HEARD.
CARDIOVASCULAR SYSTEM EXAMINATION
INSPECTION :
BILATERALLY SYMMETRICAL CHEST PRESENT
NO SCARS, SINUSES
PALPATION:
INSPECTORY FINDINGS ARE CONFIRMED
APEX BEAT NORMAL
ON AUSCULTATION :
S1 S2 HEARD, NO MURMURS OR ADDITIONAL HEART SOUNDS
CENTRAL NERVOUS SYSTEM EXAMINATION
HIGHER MENTAL FUNCTIONS INTACT
CRANIAL NERVES INTACT
NO FOCAL NEUROLOGICAL DEFECITS
COURSE IN THE HOSPITAL-
PATIENT WAS ADMITTED IN GANDHI HOSPITAL YESTERDAY EVENING AND WAS GIVEN IV FLUIDS AND GOT TREATED FOR DKA
AND CAME TO KAMINENI FOR FURTHER MANAGEMENT. WHEN HE ARRIVED HERE HIS GRBS WAS 254MG
URINE FOR KETONE BODIES POSITIVE .METABOLIC ACIDOSIS WAS PRESENT ON ABG.
AFTER GIVENINJ.HAI 4U IN 39ML NS @4ML/HOUR ACC TO GRBS(HIGH OR LOW) FOR ONE DAY ,THEN IN THE MORNING PATIENT WAS RELIVED FROM SYMPTOMS
AND BRIDGED TO INJ. HAI S/C (TID)AND INJ.NPH S/C(BD) BY EVENING
PATIENT IS BEING DISCHARGED IN HAEMODYNAMICALLY STABLE CONDITION.
Investigation
2D ECHO
EJECTION FRACTION:59 PERCENT
NO MR/TR/AR
GOOD LV SYSTOLIC FUNCTION
NO DIASTOLIC DYSFUNCTION
NO PAH/PE
ECG ON 15/07/23
SINUS TACHYCARDIA
USG ABDOMEN ON 15/07/23
RT KIDNEY 9.8X4.2 CM
LT KIDNEY 10.8X5.1 CM
IMPRESSION RAISED ECHOGENICITY OF BILATERAL KIDNEYS
URINE CULTURE :NO GROWTH
ON 15/07/2023:
HEMOGRAM
HB-14.7 GM/DL
TLC-16300 CALLS/CUMM
PLATELETS- 2.03 LAKH/CUMM
RBS: 224 MG/DL
HBA1C:6.8 MG/DL
RFT:
S.CREATITINE-0.8 MG/DL
BLOOD UREA-44MG/DL
NA-139
K- 4.6
CL-102
CA1.22
LFT:
T.BILIRUBIN-6.70 MG/DL
D.BILIRUBIN- 0.32 MG/DL
ALP- 245
AST-13
ALT-12
TOTAL PROTEIN-6.9MG/DL
ALBUMIN- 4.38MG/DL
A/G RATIO- 1.74
CUE
ALBUMIN 2+
SUGARS 3+
RBC NIL
PUS CELLS 3-4
URINE FOR KETONE BODIES: POSITIVE
ABG
PH 7.286
PO2 114
PCO2 23.3
HCO3 14.3
BLOOD GROUP B POSITIVE
ON 15/07/2023
ELECTROLYTES
NA 136
K 4.1
CL 101
CA 1.23
ON 16/07/2023
HB 14.8
TLC 7900
PLT 1.50
ABG
PH 7.347
PCO2 26.2
PO2 120
HCO3
16.8
ELECTROLYTES
NA 138
K 3.6
CL 100
CA 1.19
ON 19/07/2023
HB 14.6
TLC 4900
PLT 1.59
PCV 42.1
MCV 82.1
Treatment Given(Enter only Generic Name)
IV FLUIDS NS 0.45% @250ML/HOUR
INJ.5%DEXTROSE@100ML/HOUR (INCREASE OR DECREASE ACC TO GRBS)
INJ.KCL 40MEQ IN 0.45NS IV OVER 4-5 HOURS
INJ.HAI SC/TID PREMEAL 14U--14U--14U
INJ .NPH SC/BD PREMEAL 12--X--12U
SYP.POTCHLOR PO/TID 10ML
Advice at Discharge
1.INJ.HAI SC/TID PREMEAL 14U--14U--14U (PRE MEAL)
(6AM--1PM--6PM)
2.INJ .NPH SC/BD PREMEAL 12--X--12U (PRE MEAL)
(6AM--X-8PM)
3.SYP.POTCHLOR PO/TID 10ML
4. STRICT DIABETIC DIET AND HYPOGLYCEMIC SYMPTOMS HAVE BEEN EXPLAINED
