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:


Position of trachea; midline
Position of Apex beat; left5ics 1cm medial to mid clavicular line
Symmetry of chest : symmetrical and elliptical
Movement of chest ; normal
 
Palpation ;
Position of trachea,apical pulse is confirmed
No tenderness over chest wall,no crepitation s,no palpable added sounds,no palpable pleural rub
Percussion;
Resonant note heared,no obliteration on traubes space

Auscultation ; 

BAE-PRESENT, 

Per abdomen:

Per abdomen;

Shape; scaphoid
Umbilicus; central
Movements ; normal
No visible pulsations or engorged veins,no visible peristalsis
Skin over abdomen ;normal
Palpation; soft non tender,
*  no tenderness,or local rise of temperature
Percussion ;
Liver; resonant note heared
No fluid thrills,shifting dullness
Auscultation;

Bowel sounds are heared


CVS:


Inspection;
Position of trachea ;midline
No visible pulsations,

Precordial bulge : absent
Shape of chest; bilaterally symmetrical
Apex beat ; left 5th inter costal space1cm medial to mid clavicular line
Palpation; no palpable thrills,parasternal heaves are palpable
Percussion ; 
Auscultation; S1,S2 heart sounds are heared , 

CNS:

Higher mental functions intact

Reflexes- present
Power,muscle tone- normal
Gait- normal
No meningeal signs
Cranial nerves - intact

Investigations:

Hemogram:

       HB.     TLC     PC.   PCV  MCV. MCH  MCHC  

D-1 10.3  14,900 5.45l 34.7 70.   20.8.    29.7  
   
D-2 8.9.    12700 4.48  29.2 69.4 21.1.  30.5

D-3 9.7.  16700. 5.96. 31.4 68.3. 21.1. 30.9

D-4

 D-1 impression:.  microcytic hypochromic Anemia with neutrophilic leukocytosis and thrombocytosis
D-2: microcytic hypochromic Anemia with neutrophilic leukocytosis

CUE:

Appearance:
Albumin:++
Sugars:++
Pus cells:4-5
Epithelial cells:3-4

Urine for ketone bodies: positive
 
Urinary electrolytes:

Blood grouping and typing: O positive

LFT:
       TB.  DB.  AST.  ALT. ALP. TP.   Alb.  A/G

D-1 0.87 0.15 12.  16. 337.  7.1. 3.6. 1.13

D-2 2.04 0.47 18.  12.  293.   6.2. 3.2. 1.09

D-3 0.94 0.20 19   10. 276.  5.9. 2.99. 1.03

D-4

D-5


RFT:
    S.u.  S.cr.  Na.  K.  Cl.  I Ca.   Ca.  Mg.  P

D1 27. 0.6.  132  4.  102. 1.07

D-2 21. 0.6.  136. 3.4 106. 1.05

D3 22. 0.6.  135. 2.6. 108. 0.97

D4

D-5

RBs
FBS: 213
Plbs:
Hba1c: 7.6

Serology: negative

PT:
INR:
Aptt:
BT:2 min 30 secs
CT: 5 min 00 secs
 Serum osmolality: 297
Pus culture sensitivity:


On 18/1/23:
Klebsiella pneumonia isolated




Abg:
         

D-1






D-2



D-3







D-4












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






S/p: 
Debridement + split skin grafting done under spinal anaesthesia for gluteal ulcer on 31/1/23

On4/2/23





On6/2/23



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