DKA

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I have 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 

35 year old male farmer by occupation is brought to opd with 

C/O vomiting since 8days 

History of presenting illness:-

Patient was apparently asymptomatic one month back since then he is having occasional episodes of vomitings which are increased in frequency since past  8 days that is of  1 - 2 episodes per day,Non projectile,Non bilious,Not blood tinged,Food particles as content associated with fever,Not associated with pain abdomen

8 months back patient suffered with ? Chickenpox for 1.5 month .

2months after recovery from chicken pox he is diagnosed as having  DM (probably type 1)when patient presented with unconscious state

H/o of  shortness of breath( grade 2) for 1 month  which is intermittent ( increased during night),Associated with cough and fever

Burning micturation present

Cough initially Non productive later productive ,Associated with scanty sputum,Non blood tinged

Fever is low grade, intermittent,associated with night sweats not associated with chills and rigors   

Weight loss of 8 to 10 kgs  from past 3 months

Progressive increase in weakness which is  increased in severity since past 10days 

Decreased appetite since past 1 month 

Since 4months he was on Mixtard  10 units once daily for his DM 

But Patient stopped using these for past 1 month 

N/k/c/o htn asthma cad tb epilepsy

Non alcoholic,Non smoker,No relevant family history 

Treated outside for UTI - ecoli  with antibiotics

Vitals - 

Bp:- 140/80 mmHg

PR :-123bpm.

Sat- 100 on RA

Grbs - High at presentation

RR- 26cpm

Temp- 100°F

Systemic examination:-

Cvs - S1S2

Rs- bae+

Started on ivf NS bolus f/b 75ml/hr 

Inj Hai 6u IV hourly---> infusion @6u/hr

2d echo - ivc 1.28cm ,collapsible

Normal chambers

Mild lvh

Hemogram:- 

Hb-7.2

TLc- 22,800

Plt- 3.3 lakhs

Microcytic hypochromic

Urea-206

Creat 4.0

Na-131

K-4.7

Cl- 95

Urine for ketones negative

Rbs- 485 mg/dl 

Course in the hospital:- patient presented to our hospital with the above mentioned complaints, thorough clinical and metabolic evaluation was done. 

GRBS was high, RBS was 485mg/dl, urine for ketones was negative and ABG showed metabolic acidosis 

Patient was treated for uncontrolled sugars with insulin Inj.Hai @6ml/hr infusion and tapered the insulin according to the GRBS blood sugar levels were controlled.

As the patient was having recurrent Urinary tract infections and fever spikes USG abdomen was done which showed b/l bulky kidneys with altered echo texture suggestive of pyelonephritis and left sided hydroureteronephrosis .

Urology opinion was taken ivo bilateral pyelonephritis and CT-KUB was advised , IV Antibiotics Inj.Piptaz 2.25gm /IV/TID was    given for 4days

Ophthalmology referral done showed :- mild NPDR changes noted and adviced strict glycemic control, review to opthalmology opinion for every 6 months,

Date-12/4/23 Urine culture report showed methicillin sensitivity staphylococcus aureus resistance to penicillins and sensitivity to co trimaxazole ,….and I/v/o renal failure creatinine clearnce 23ml/hr cotrimoxazole (Dose adjustement was done(50%of regular dose) was given for 5 days .

I/v/o anaemia evaluation was done, Hb-7.2 gm/dl,Microcytic hypo chronic ,Reticount :-0.5

Stool for occult blood( + )

Surgery opinion was taken I/v/o previous h/o hemorrhoids and constipation 

P/R examination showed - skin around the glutial clefts normal 

-no external skin tags, fissures, haemorrhoids, sinuses or fistulas 

-surrounding external skin stained with stool .

-anal tone is normal

-hard stoll pellets found in the rectum

- all stool pellets have been cleaned upto the level of finger insertion.

-glove stained with dark yellow coloured stool 

Adviced - syp cremaffin 30ml/po/hs 

-proctoscopy after soap water enema 

- advice colonoscopy to rule out  losses ,gi bleed 

-upper GI endoscopy i/v/o any upper GI bleed 

Upper GI endoscopy was planned I/v/o any upper GI bleed which showed esophageal candidiasis, bile reflux gastritis 

Endocrinology opinion was taken and was suggested Inj Lantus 10 units at @10pm

Urology opinion was taken again  and Fosfomycin 3gm sachets alternative days for 1 week (3 doses) if patient did not improve symptomatically. 

Nephrology opinion was taken for presence of ? Diabetic nephropathy and was suggested tab lasix 20mg PO OD for 3days

INVESTIGATIONS :- 

Hemogram:-

Hb:- 7.2----6.2----6.8----6.0--6.0

Pcv:- 22.5----20.4----22.5----19.9--19.9

TLC:- 22,800----14,480---9,500----7500-- 7300

RBC:- 3.3----2.89----3.16----2.81--2.78

Platelets:-4.2----3.47----4.0----4.18--4.10

RETICULOCYTE COUNT   :- 0.5

RFT :-

Blood urea:- 206----147----77----60--35

Sr creatinine:- 4.0----3.4----2.3----2.3--2.6

S.Na:- 131----139----137----139--139

S.K:- 4.7----4.0----3.8----3.8--3.7

S.Cl:- 95----104----106----104 

Ionized Ca:- 1.04--1.08--1.07--1.13

LFT:-

Total bilirubin:- 1.04

Direct bilirubin:- 0.23

SGPT:- 14

SGOT:-11

ALP:- 284

TOTAL PROTEIN:- 8.0

Albumin :- 2.5

A/G ration:- 0.45  

24 hour URINARY ELECTROLYTES:-

Na:- 176 

Ca :- 297 

Phosphorous:-0.87 

USG report:- 

Review USG:- 

2D echo report:- 

Upper GI endoscopy:-

Chest x ray:-

Xray kUB-

ECG:- 

CT:- 

Report

C& S blood and urine:-

DIAGNOSIS:- 

Uncontrolled sugars secondary to non compliance to medication. (Resolved )

Acute kidney injury secondary to? Pre renal secondary to ? Sepsis ?

bilateral pyelonephritis with left hydroureteronephrosis 

with anemia (microcytic hypochromic) secondary to?

GI losses 

? Iron deficiency anemia 

Treatment Given :- 

1.IVF- NS @ 75ml/hr

2.Insulin infusion @8 U/hr increase or decrease acc to GRBS(algorithm 2)

3.GRBS charting hourly and inform PG

4.Monitor Temp, PR,RR,BP hourly

5.Strict input output charting. 

6.trimethoprim + sulphamethoxazole is given for 5 days starting from 16th 

ADVICE AT DISCHARGE:- 

1.Inj.HAI sc/tid 

(8am ---1pm---8am)

(14u----14u-----14u)

2.Inj.NPH sc/bd 

  (8am----8pm)

  (10u------10u) 

3. Trimethoprim (160mg)+ sulphamethoxazole (800mg) po/od  for 2 days  (day 6,7)

4.Tab Orofer XT po/bd 

5.strict diabetic diet . 

GRBS CHARTING:- 

12/4/23 

2pm --- high grbs (>600)-- 6ml/hr iv infusion of hai started  

4pm-- high grbs---8ml/hr iv infusion of hai 

7pm--232----4ml/hr  

8pm---176--2ml/hr 

13/4/23 

12am---160-- 2ml/hr 

2am--142---1.5ml/hr 

4am---154--1.5ml/hr 

8am--150--1ml/hr 

10am--142--1ml/hu+10u hai+8u nph

1pm-119--10u hai 

8pm--116 

14/4/23 

12am-141 

2am-125 

8am-145---6u hai+6u nph 

2pm--102--4u hai 

7pm--160--6u hai+6u nph 

15/4/23

8am ---156----6u hai+6u nph 

11am----396

2pm---262--10u hai 

4pm ----432

6pm---434---14u hai 

8pm----360---10u hai +8u nph 

10pm---179

16/4/23

2am----98

8am -----140---10u hai+10u nph 

10am ----257

12pm----288---16u hai 

4pm---303

8pm----237----14u hai+10u nph 

10pm----295

17/4/23

12am----275

2am----210

4am---145 

8am---119--10u hai+10u nph 

10am--199

2pm---187-- 14u hai 

4pm---157

8pm---121---10u nph+14u  hai 

10pm ---188 

18/4/23 

2am --148 

8am---116 

2pm---112 --12 hai 

4pm---391 

8pm----395--16u hai-10 nph 

19/4/23 

2am---161 

8am---124--14u hai +10 u nph 

1pm--108---14u hai 

8pm---92 ---10u hai+6u nph 

20/4/23 

2am---141 

8am---147---14u hai+10 nph