60M with DKA; K/C/O DM Since 4Years

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Cheif Complaints :
A 60 Years old Male Who is a resident of Indrapalanagar (Village ) ; Ramannapet ( Mandal ) ; Yadadri ( district) Who is a Mason by Occupation Came to Casualty on 21/07/23 With Complaints of 
Vomitings Since Today Morning ( 3am ) 
Pain Abdomen Since Today Morning ( 3am )
Difficulty in Swallowing Since Today Afternoon (12PM)

Daily Routine & Drinking Habbit : 
Wakes Up at 6am , goes to farm & Does Some Work if any & Comes Back , Fresh Up & Have his Breakfast. From 9 to 10am He calls all his Labourers. Starts his Work at 10am, He Returns to Home for Lunch for 1hour, Returns to Work & Ends at 7PM. He Started Drinking alcohol along with his Friends Now & Then Since 17 years of age which turned to habbit of  Drinking Daily From 20 years of age When he started working as Mason.Drinks about 90-180ml Daily & Increased Quantity During Festivals.
He Returns to Home at around 7:30PM & Have his Dinner at Around 9:00PM & Goes to Bed after Dinner.After Diagnosing with Diabetes he stopped taking alcohol Dialy but still continued to Take alcohol Now & then.

Work Routine : 
Before 20 years of age he used to help his parents in Farming; They used to grow paddy in their 2 Acres of Land in their Village.Patient Started Working as Mason From 20 Years Of Age. He Heirs Some Labourers & Constructs Houses & Earns Around 1000/day

History of Present Illness 

2019 : 
Patient Was Apparently Asymptomatic 
4 Years Back ( 2019 ) then started Loosing Weight, Had Increased Urination, Generalized Weakness, & Couldn't Cope Up with his Work his daughter brought to Our Hospital & Was Found to Be Diabetic ( RBS - 500mg/dl ) & He was Started on OHAs.After Diagnosing with Diabetes He Was Irregular to his Work & Even if Goes He doesn't work & gets the Work Done by Labourers

2021 : 
His symptoms did not Improve even after Starting OHAs. So 2 years Later ( Since 2021 ) He was Shifted to INSULIN ( INJ.MIXTARD 20U at Morning; 15U at Night) & TAB.METFORMIN 500MG at afternoon.

1 Month Back Patient Developed Itching all over the body which is more pronounced from both Groins upto both knee Joints for which to he went to some quacks where they gave some medication & not to eat some kinds of Food So Since then He was not eating Well & Took Insulin at Reduced dose & Sometimes stopped taking insulin
He Missed taking Night Insulin Dose on Wednesday ( 19/7/23 ) , On Thursday ( 20/7/23 ) Night He Had Rice with Dal & Tomato Curry without taking Insulin & Slept after Having Food. At 3am He Had 1 Episode of Vomiting Which is Non Projectile , Containing Food Particles, Non Blood / Mucus Stained. He Had Similar Such Vomiting Episode at 6:30am & Around 10am. At that Time attenders called RMP Doctor to Home & Found to Have High Sugars for Which he gave INSULIN Injection & Was asked to go to Hospital & get checked. After INSULIN Injection he was better Symptomatically & Patient Developed Difficulty in Swallowing to both Food & Water From 12PM due to Vomitings then he was brought to Our Hospital around 1PM
He Stopped Gng To Work Since 10 days 

Diet Habbit :
After Diagnosing with Diabetes his Diet was 
6:30am - Drinks Ragi Java ; 9:00am - Eats Gatka ; Afternoon : Rice ; Night : Jonna Roti 
These Habbits were Changed Since 1 year he started eating whatever he wants to eat ( Mostly Rice 3 Times/day ) inspite of Doctors & Family Members advice.

Family History: 
Patient & His Wife Stays in their Village
He has 1 Son ( Younger ) & 1 Daughter ( Elder ).
Son : Assistant Manager in a Bank in Hyderabad, He Stays in Hyderabad Along with his Children & Comes to see his parents Weekly Once 
Daughter : Home Maker, Stays in Narketpally along with her Husband ( PRO in KIDS ) & Children

General examination:

Patient is conscious, coherent and cooperative  He is Moderately 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-100/60 mm of Hg 
PR - 140bpm
RR - 28cpm
Temp-98.7F
Spo2 - 98% on Room Air
GRBS - High

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

Investingations : 
Serology : 
Hemogram ( 21/7/23 ) 
Hemogram (22/7/23 ) 
CUE ( 21/7/23 )
RFT ( 21/7/23)
Serum Electrolytes on 21/7/23 11PM
RFT on 22/7/23
LFT on 21/7/23
ABG on 21/7/23 at 3PM
ABG on 21/7/23 at 11PM 
ABG on 22/7/23 at 5am 
Serum Osmolality on 21/7/23
Urine For Ketone Bodies on 21/7/23
ECG on 21/7/23
CXR on 21/7/23
2D Echo on 22/7/23
USG Abdomen on 22/7/23
Treatment : 

21/07/2023: 
1.IV fluids - 2 NS Bolus f/b NS @150ml/hr
                          ↓
           Inj. HAI 6units IV stat.
                          ↓
           Inj. HAI 6 units IV stat.
                          ↓
     Inj. HAI 1ml in 39ml NS, at 6ml/hour.
   (Increase / Decrease according to GRBS)
2. Monitor GRBS hourly.

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