57M DKA ; Chr.Pancreatitis; CKD ; DM ; HTN

 Case History and Clinical Findings

C/O ALTERED SENSORIUM SINCE 6 DAYS.

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK THEN HE STOPPED USING INJECTION MIXTARD SC/BD SINCE 3 DAYS.H/O OF IRRELEVANT TALK SINCE YESTERDAY BUT ABLE TO RECOGNISE ATTENDERS.PATIENT IS ABLE TO MOVE ALL LIMBS AND NO H/O INVOLUNTARY MOVEMENTS.

H/O LOW GRADE FEVER SINCE 6 DAYS,INTERMITTENT IN NATURE,TEMPORARILY RELIEVED ON MEDICATION.

NOT A/O WITH BURNING MICTURITION,COLD, COUGH,VOMITING,LOOSESTOOLS.

NO C/O SOB,CHESTPAIN,PALPITATIONS,ORTHOPNRA,PND,PEDAL EDEMA OR DECREASED URINE OUTPUT.

PAST H/O:

H/O SIMILAR COMPLAINTS IN FEB 2022,PATIENT WAS ADMITTED IN OUR HOSPITAL AND WAS DIAGNOSED AS HHS WITH DIABETIC NEPHROPATHY.

PATIENT HAD H/O HIGH GRADE FEVER WITH CHILLS FOR 4 DAYS AND H/O STOPPAGE OF OHAS FOR 3 DAYS.
K/C/O DM2 SINCE 1.5 YEARS.
K/C/O CHRONIC PANCREATITIS AND CHRONIC KIDNEY DISEASE SINCE 1 YEAR
H/O PULMONARY TB 2 YEARS AGO,USED ATT FOR 6 MONTHS

GENERAL EXAMINATION:
PATIENT IS CONSIOUS
NOT ORIENTED TO TIME ,PLACE AND PERSON
NO PALLOR, ICTERUS,CLUBBING, CYNOSIS, LYMPADENOPATHY
VITALS:
BP:130/80MMHG
PR:86 BPM
RR:18 CPM
SPO2:96%'
GRBS:235MG/DL
SYSTEMIC EXAMINATION:
CVS S1, S2+ NO MURMURS HEARD
RS: BAE+
P/A: SOFT NON TENDER
CNS:NFND
REFLEXES: BICEPS TRICEPS SUPINATOR KNEE ANKLE
RIGHT +2 +2 +2 +2 +2
LEFT +2 +2 + 2 + 2 +2

COURSE IN HOSPITAL : PATIENT CAME WITH ABOVE COMPLAINTS AND THOROUGH CLINICAL EXAMINATION AND NECESSARY INVESTIGATIONS WERE DONE.
GRBSRECORDING WAS 'HIGH'. WITH URINE FOR KETONES BODIES POSTIVES AND ABG SHOWED METABOLLIC ACIDOSIS . INJ.HAI 6U IV STAT WAS GIVEN FOLLOWED BY INJ.HAI 1ML WITH 39ML NS INFUSION @ 6ML/HR WAS GIVEN AND INCREASED OR DECREASED ACCORDING TO GRBS. ON DAY 2 INJ.HAI INFUSION WAS GIVE @2ML/HR AND WAS INCREASED OR DECREASED ACCORDING TO GRBS. BY DAY 3 BLOOD SUGARS WERE UNDER CONTROL AND INJ.HAI WAS GIVEN SC TID ACCORDING TO GRBS PRE-MEAL. EMPERICALLY IV ANTIBIOTICS(CEFTRIAXONE) WAS GIVEN FOR 5 DAYS. ALTERED SENSORIUM WAS GRADUALLY IMPROVING.
PSYCHIATRY OPINION WAS TAKEN IMP-PSYCHOSIS NOS,PARAPHRENIA.
ADVISED FOR EEG.CPK.AMMONIA,PROLACTIN,GGT.TREATMENT-T.ARIPRAZOLE 5MG
X-1-X FOR 2DAYS
X-1-X 10MG FOR 7DAYS
T.LORAZEPAM 1MG
X-X-1 FOR 2DAYS.
PATIENT HAS SYMPTOMATICALLY IMPROVED AND IS BEING DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION.
2D ECHO WAS DONE AND IT SHOWED
EJECTIONFRACTION:58%
NO MR/AR/TR
NO RMWA.NO AS/MS
GOOD LV SYSTOLIC FUNCTION.
DIASTOLIC DYSFUNCTION.
PATIENT WAS DIAGNOSED WITH ALTERED SENSORIUM SECONDARY TO DIABETIC KETOACIDOSIS AND SYMPTOMATIC TREATMENT WAS STARTED.
PATIENT WAS DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION

Diagnosis
ALTERED SENSORIUM (RESOLVING) SECONDARY TO DIABETIC KETOACIDOSIS
K/C/O CHRONIC PANCREATITIS SINCE 1 YR
K/C/O CHRONIC KIDNEY DISEASE SINCE 1 YR
K/C/O TYPE II DM AND HTN SINCE 1YR
PSYCHOSIS NOS ,PARAPHRENIA

Investigation:-
HEMOGRAM
26/7/23
HB:13G/DL
TLC:11,300

N/L/E/M/B:86/10/1/3/O
PLC:1.59
27/07/23:
HB:11.4G/DL
TLC:17,300

N/L/E/M/B:77/15/1/7/O
PLC:1.60
28/7/23
HB:10.9G/DL
TLC:13,400

N/L/E/M/B:72/17/2/7/O
PLC:1.5
29/07/23:
HB:10.5G/DL
TLC:9,800

N/L/E/M/B:74/17/2/7/O
PLC:1.3
30/7/23
HB:10.8G/DL
TLC:9300

N/L/E/M/B:75/16/4/5/O
PLC:1.5
31/7/23
HB:9.2
TLC:14,300

N/L/E/M/B:80/10/2/8/0
PLC:2.3
CUE:
ALBUMIN:3+
SUGARS:4+
PUSCELLS:5-6
EC:2-4
RBC-NIL
RFT:

26/07/23
SERUM CREATININE:3.2
BLOOD UREA:91
NA+:133
K+:4.1
CL-:98
CA+2:1.07

27/07/23:
SERUM CREATININE:3.7
BLOOD UREA:99
NA+:131
K+:4
CL-:97
CA+2:1.09

28/07/23:
SERUM CREATININE:3.4
BLOOD UREA:89
NA+:136
K+:3.8
CL-:102
CA+2:1.12

29/7/23
SERUM CREATININE:3.1
NA+:139
K+:3.5
CL-:104
CA+2:1.16

30/07/23:
SERUM CREATININE:3
BLOOD UREA:71
NA+:140
K+:3.8
CL-:103
CA+2:1.01

31/07/23;
SERUM CREATININE:2.9
BLOOD UREA:65
NA+:138
K+:5.4
CL-:103
CA+2:1.13
LFT:
TB:3.26
DB:0.35
AST:13
ALT:16
ALP:426
TP:8.1
ALBUMIN:4.22
A/G:1.09

1/8/2023
HEMOGRAM
HB:10.9
TLC:9,900

N/L/E/M/B:62/30/1/7/0
PLC:1.65
RFT
UREA:57
CREATINE:2.8
NA+-136
K+3.6
CL-99

URINE FOR KETONE BODIES:POSITIVE
SPOT URINE PROTEIN:127
SPOT URINE CREATININE:30
SPCR:4.23
24 HR URINE PROTEIN:94
24 HR URINE CREATININE:2.57
BGT:A POSITIVE
APTT:36 SEC
PT:20 SEC
INR:1.4
RBS:650
HBA1C:8G%
SERUM IRON :83
SERUM OSMOLALITY:307.1
SEROLOGY :NEGATIVE

USG -
IMPRESION :
B/L GRADE II RPD CHANGES
B/L RENAL CALCULUS
LEFT RENAL CORTICAL CYSTS
ACUTE ON CHRONIC CALCIFIC PANCREATITIS
2D ECHO :
EJECTIONFRACTION:58%
NO MR/AR/TR
NO RMWA.NO AS/MS
GOOD LV SYSTOLIC FUNCTION.
DIASTOLIC DYSFUNCTION

ECG -
NORMAL SINUS RHYTHM

Treatment Given:-
1)IVF NS @75 ML/HR
2)INJECTION HAI SC/TID(PRE MEAL)
8U-8U-8U
3)TAB AMLODIPINE 5MG/PO/OD
4)GRBS 7 HRLY MONITORING
5)STRICT I/O CHARTING

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