Diabetic ketoacidosis with perianal abscess
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
K.shirisha
Rollno;68
A 18 year old female came to casuality on 3/1/23
With chief complaints of
Sob since 2days
feversince 1 week,,
Pain and swelling in the perianal region since 10 days
HOPI: The patient was apparently asymptomatic 9 years ago
Course of events:
9 years ago:
She had polyuria,polydipsia,polyphagia weakness and weight loss due to which she visited a local hospital and there her grbs was high and was diagnosed to be having diabetes and started on insulin injection and was using since then?
Inj mixtard 20U - x- 15U.
In between due to raised sugar levels she develops abdominal pain and consults a doctor and takes fluids and high dose of insulin
1 week ago:
Patient had swelling over Analverge a which was initially 1x 1cns and progressed to the present size of 4x4 cms associated with discharge of pus and mixed with blood, associated with High grade fever associated with chills and rigor for which she consulted local doctor and prescribed antibiotics and she used for 5 days and also developed nausea due to which she was not on proper diet and so she decreased her insulin dosage to 5u - 5u on her own since 3 days and developed sob on rest since 2 days and yesterday as sob was increased and got her Grbs checked at home and it was 480mg/dl and was taken to local hospital and was given injection ( not known)and since today morning her sob was increased went to hospital and RBS being high insulin14u HAI given and referred here for further management
Past history:
H/O similar complaints of swelling in inner thighs and in gluteal region 1 year back as she has taken covid vaccine on that time and she consulted local doctor and recieved antibiotics ( amoxiclav 625mg/po/bd for 5 days and also herbal medicine for swelling local application it got relieved
Not a k/c/o hypertension, Tb,asthma, epilepsy, thyroid disorders
Menstrual history:
Age of menarche: 13 years
Menses: regular,28 days cycle
Flowincreased associated with clots and pain
Personal history:
Appetite: decreased
Diet: mixed
Bowel and bladder: regular
Sleep: adequate
Addictions: no
Family History: her father is a known case of diabetes since 16 years and he was using insulin mixtard 2 times daily
General examination:
Patient was conscious, coherent, cooperative
Pallor: present
Icterus: absent
No cyanosis, clubbing, lymphadenopathy,edema
Vitals:
Temperature: 101 F
Bp: 120/70mmhg
PR: 92 BPM
RR: Tachyponeic at the time of admission
21cpm
Spo2: 98% on ra
Grbs:
Surgery referral notes:
On local examination:
Swelling was in perianal region which was initially 1x1 cms and progressed to present size of 4x4 cms
Pus discharge present
Skin over swelling: reddish colour
Palpation:
Tenderness+
Local rise of temperature
Induration of skin over the swelling+
Visible pus discharge
Pictures captured by Dr lohith pgy1
Incision and drainage of pus was done under spinal anaesthesia
After iand d of abscess picture:
On6/1/23:
On 7/1/23:
Systemic examination:
Respiratory system:
BAE-PRESENT,
Per abdomen:
Per abdomen;
CVS:
CNS:
Higher mental functions intact
USG abdomen:
Internal echoes noted in urinary bladder
? Cystitis
ECG:
Chest x ray:
2d echo:
No AR /MR/TR
No RWMA,No As/ps
Good lv systolic function
No diastolic dysfunction
No pAH/pe
Diagnosis:
Diabetic ketoacidosis with Type 1 DM since 6 years with perianal abscess
S/P : incision and drainage of abscess done under spinal anaesthesia ( 3/1/23)
Treatment:
Iv fluids Ns@100ml/hr
Inj Human Actrapid insulin Sc/TID
12u- 12u- 12u
Inj NPH sc/BD
15u- × -15u
Inj meropenam 1gm/iv/Bd d2
Inj Amikacin 500 mg/iv/Bd d2
Inj metrogyl 500 mg/iv/Tid d3
Inj pan 40 mg/ iv/ bd
Inj neomol 1 gm/iv/bd
Inj Tramadol 2ampoules in 100ml Ns/iv/bd
Inj Zofer 4 mg/ iv/bd
Inj kcl 20 meq in 100 ml Ns/iv /stat
Tab orofer xt/ po/ od @2pm
Tab Dolo 650mg/po/Tid
Sitz bath/ qid
Strict I/O charting
Grbs 7 print profile
6/1/23
: No fever spikes
Stools passed
O:
Patient was conscious,coherent, cooperative
GCS: E4V5M6
PR 106BPM
BP 120/70 MMHG
RR 21 CPM
Spo2:98%on RA
GRBS :
8am: 148mg/dl
10am: 162mg/dl
12pm:269 mg/dlinj hai 14 u
4pm: 193 mg/dl
7pm: 142 mg/dl inj Hai 12+inj NPH 15 u
10pm: 207mg/dl
2am: 112mg/dl
8am:170mg/dl 12u hai + 15 u nph
I/O: 2350ml/ 950ml
CVS: S1,S2+
No murmurs
CNS: HMF intact
RS: BAE+, clear
P/A: soft,nontender
BS: heared
L/E of wound:
Wound covered with slough
Hemogram:
HB:7.8
TLC:11,800
PC:4 .40l
Impression: microcytic hypochromic Anemia with leukocytosis
Lft:
TB:1.03
DB:0.20
AST:18
ALT:09
ALP:238
Tp:5.2
Alb:2.7
A/G:1.07
RFT:
S.urea:12
S.cr:0.5
Na:137
K:2.9
Cl:106
ICA:0.95
A:Diabetic ketoacidosis with Type 1 DM since 6 years with perianal abscess
S/P : incision and drainage of abscess done under spinal anaesthesia ( 3/1/23)
P:
Iv fluids Ns@100ml/hr
Inj Human Actrapid insulin Sc/TID
14u- 14u- 14u
Inj NPH sc/BD
15u- × -15u
Inj meropenam 1gm/iv/Bd d3
Inj metrogyl 500 mg/iv/Tid d4
Inj pan 40 mg/ iv/ od
Inj neomol 1 gm/iv/bd(if temp>101 f)
Inj Tramadol 2ampoules in 100ml Ns/iv/bd
Inj Zofer 4 mg/ iv/bd
Inj kcl 20 meq in 100 ml Ns/iv /stat
Tab orofer xt/ po/ od @2pm
Tab Dolo 650mg/po/Tid
Tab chymeral forte /po/Tid
Tab mvt/po/od
Tab vitc/po/od
Diabetic protein powder in 1 glass of water Tid
Sitz bath/ qid
Strict I/O charting
Grbs 7 print profile
S: pain at the surgical site
No fever spikes
Stools passed
O:
Patient was conscious,coherent, cooperative
GCS: E4V5M6
PR 106BPM
BP 120/70 MMHG
RR 21 CPM
Spo2:98%on RA
GRBS :
8am: 170mg/dl 12u hai+ 15 u nph
10am: 290mg/dl
12pm:79mg/dlinj hai 14 u
4pm: 158mg/dl
7pm: 84mg/dl inj Hai 12+inj NPH 14 u
10pm: 241mg/dl
2am: 212mg/dl
8am:280mg/dl 12u hai + 15 u nph
I/O: 2500ml/1300ml
CVS: S1,S2+
No murmurs
CNS: HMF intact
RS: BAE+, clear
P/A: soft,nontender
BS: heared
L/E of wound:
Wound covered with slough
Hemogram:
HB:7.8-8.4
TLC:11,800-12,500
PC:4 .40l-5.40l
Impression: microcytic hypochromic Anemia with leukocytosis
Lft:
TB:1.03-065
DB:0.20-0.10
AST:18-16
ALT:09-12
ALP:238-249
Tp:5.2-5.6
Alb:2.7-2.8
A/G:1.07-1.01
RFT:
S.urea:12-13
S.cr:0.5-0.7
Na:137-132
K:2.9-3.2
Cl:106-102
ICA:0.95-0.98
A:Diabetic ketoacidosis with Type 1 DM since 6 years with perianal abscess
S/P : incision and drainage of abscess done under spinal anaesthesia ( 3/1/23)
P:
Iv fluids Ns@100ml/hr
Inj Human Actrapid insulin Sc/TID
14u- 14u- 14u
Inj NPH sc/BD
15u- × -15u
Inj meropenam 1gm/iv/Bd d3
Inj metrogyl 500 mg/iv/Tid d4
Inj pan 40 mg/ iv/ od
Inj neomol 1 gm/iv/bd(if temp>101 f)
Inj Tramadol 2ampoules in 100ml Ns/iv/bd
Inj Zofer 4 mg/ iv/bd
Syp potchlor 15 ml in 1 glass of water /po/Tid
Tab orofer xt/ po/ od @2pm
Tab Dolo 650mg/po/Tid
Tab chymeral forte /po/Tid
Tab mvt/po/od
Tab vitc/po/od
Diabetic protein powder in 1 glass of water Tid
Sitz bath/ qid
Strict I/O charting
Grbs 7 print profile
9/1/23
S: pain at the surgical site
No fever spikes
Stools passed
O:
Patient was conscious,coherent, cooperative
GCS: E4V5M6
PR 106BPM
BP 120/70 MMHG
RR 21 CPM
Spo2:98%on RA
GRBS :
8am: 222mg/dl 14u hai+ 15 u nph
10am: 130mg/dl
12pm:143mg/dlinj hai 14 u
4pm: 85mg/dl
7pm: 84mg/dl inj Hai 12+inj NPH 14 u
10pm: 125mg/dl
2am: 212mg/dl
8am:105mg/dl 14u hai + 15 u nph
I/O: 2500ml/1300ml
CVS: S1,S2+
No murmurs
CNS: HMF intact
RS: BAE+, clear
P/A: soft,nontender
BS: heared
L/E of wound:
Wound covered with slough
Hemogram:
HB:7.8-8.4-8.0
TLC:11,800-12,500-9,700
PC:4 .40l-5.40l-5.6l
Impression: microcytic hypochromic Anemia with leukocytosis
Lft:
TB:1.03-065
DB:0.20-0.10
AST:18-16
ALT:09-12
ALP:238-249
Tp:5.2-5.6
Alb:2.7-2.8
A/G:1.07-1.01
RFT:
S.urea:12-13-18
S.cr:0.5-0.7-0.4
Na:137-132-136-138
K:2.9-3.2-2.7-2.7-3.5
Cl:106-102-103-102
ICA:0.95-0.98-1.05-0.98
Urine for ketone bodies: negative
A:Diabetic ketoacidosis with Type 1 DM since 6 years with perianal abscess
S/P : incision and drainage of abscess done under spinal anaesthesia ( 3/1/23)
P:
Iv fluids Ns@100ml/hr
Inj Human Actrapid insulin Sc/TID
14u- 14u- 14u
Inj NPH sc/BD
15u- × -15u
Inj meropenam 1gm/iv/Bd d5
Inj metrogyl 500 mg/iv/Tid d6
Inj pan 40 mg/ iv/ od
Inj neomol 1 gm/iv/bd(if temp>101 f)
Inj Tramadol 2ampoules in 100ml Ns/iv/bd
Inj Zofer 4 mg/ iv/bd
Tab orofer xt/ po/ od @2pm
Tab Dolo 650mg/po/Tid
Tab chymeral forte /po/Tid
Tab mvt/po/od
Tab vitc/po/od
Diabetic protein powder in 1 glass of water Tid
Sitz bath/ qid
Strict I/O charting
Grbs 7 print profile
Summary:
This is a case of 18 year old female came to casuality on 3/1/23 with complaints of fever,sob,Pain and swelling in the perianal region
At the time of admission she was Tachyponeic and her for Grbs was 517 mg/dl, urineketone bodies was positive
Abg was showing metabolic acidosis with high anion gap
She was started on insulin iv Hai @ 8ml/hr and
0.9% nacl was given
For perianal abscess incision and drainage of abscess done under spinal anaesthesia on 3/1/23 and she was on post op upto 7am
On 4/1/23 she was shifted to ICU and started on iv fluids and 10d, hai insulin infusion was given and antibiotics like meropenam,metrogyl ,amikacin was given for infection
Potassium correction has given her serum potassium showed 2.6meq/l
On5/1/23
Insulin dosage was fixed
Inj Hai subcutaneously
14u-14u-14u
8am-2pm-8pm
Nph
15u-15u
8am-8pm
Potassium correction was given
Discussion:
Diabeticketoacidosis is the most common complication in type 1 diabetes
What are precipitating causes in Dka?
Infection , is most common precipitating cause in known diabetes
In this patient precipitating cause was peri anal abscess and poor glcemic control
How it is diagnosed?
It is diagnosed as a combination of Hyperglycemia, metabolic acidosis, ketonuria
What is the reason for reduced serum sodium levels?
The measured serum sodium levels are reduced as a consequence of osmotic fluid shifts due to Hyperglycemia.( Reduction of 1.6meq for each 5.6mmol/l 100mg/dl rise in serum glucose.
How it was treated?
It was treated by correcting the substantial hypovolemia by giving fluids @ 100ml/hr
Hyperglycemia was treated by giving insulin ( Human Actrapid injection) intravenously
Electrolyte imbalance like hypokalemia is corrected by inj kcl infusion
How perianal abscess was treated?
Incision and drainage of abscess under spinal anaesthesia followed by debridement of slough with regular dressings
Conclusion:
Prompt surgical intervention, anti bacterial therapy, rapid restoration of glycemic control are crucial to prevent mortality in diabetes mellitus patient's complicated with abscess
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