Diabeticketoacidosis with old mi

 

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

25year old male painter by occupation since 8  years came tocasuality on 7/2/23 with complaints of

c/o fever,vomitings,constipation since 1 week

C/ o chest pain, palpitations since 1 week

C/o sob since 1week

c/o neck pain

History of present illness

Patient was apparently asymptomatic 9 years back,

Patient c/o blurring of visionin right eye for which he went to local hospital used medication eye drops(Rt>>Lt) wasn't subsided 

In 2014 patient c/o severe weight loss approximately 10-12 kgs over a duration of 2 months. And having increased appetite, increased frequency of urination with these complaints he went to Local hospital and diagnosed with type 1 diabetes mellitus and since then he was started on Mixtard insulin 28U -x - 24U and since then he is on regular follow up..

24u- x-20u now he was using

 His fbs used to be around 200-250 and ppbs around 250-300

Last HbA1c was 11.2 on feb 3rd 

Now since 1 week patient had a fever whichwas sudden in onset high grade associated with chills and rigor , no diurnal variations

C/ O vomitings 2- 3 episodes / day, non bilious non projectile food particles as content

C/ o short ness of breath on exertion which was sudden in onset gradually progressive no aggrevating and relieving factors

C/ o abdominal pain, nausea, decreased appetite

C/o constipation

C/o dry ness of mouth

C/ o neck pain which was throbbing type 

 c/o chest pain, on left side non radiating, pricking type

Palpitations, no syncopal attacks, 

No h/ o altered sensorium

No meningeal signs 

Past history:

K/c/o type 1 Dm since 9 years 

History of injury to left foot 6 months ago on plantar aspect due to prick by thorn while walking on a bare foot associated with swelling and pus discharge non blood stained for which he consulted local doctor excision was done and he was put on antibiotics followed by regular dressings for amonth

Not a k/ c/ o hypertension,tb,asthma, epilepsy,cva

Personal history:

Diet: mixed

Appetite: decreased

Bowel and bladder: regular

Sleep: adequate

Addictions:

Family history: his maternal uncle is a k/ c/ o type2 dm since 30 years 

General examination

Patient was conscious coherent cooperative

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: sbsent

Edema: absent

Vitals:

Temp: Afebrile

Bp: 110/70 mmHg

Pr: 89 bpm

Rr:18cpm

Spo2:98% on ra

Grbs: 280mg/dl

At presentation his grbs is 234  mg/dl with urine for ketones ++ 

Outside 24hr urine proteins 3920mg/day 

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:

Urine for ketone bodies positive

Ecg : old inferior wall myocardial infarction( leads2,3,Avf)

Chest x ray

USG abdomen:

B/l raised echogenicity of kidneys

Abg:

Metabolic acidosis with high anion gap

Anion gap: Na+k - cl + hco3

                   126+4-110+4.5

                  = 130-115.5

                  =15.5

Metabolic acidosis with high anion gap

  116+3.2-92+11.3

=17.9

Metabolic acidosis with normal anion gap

Hemogram:

HB: 17g/dl

TLC: 11,000

Pc: 2.31 lakhs/cumm

Impression: Normocytic normochromic Anemia with neutrophilia

Cue

Colour: pale yellow

Reaction: acidic

Albumin:+3

Sugars:+

Pus cells:2-4

Epithelial cells:2-3

RBC : nil

Lft:

TB:1 .28

DB:0.4

AST:27

ALT:25

ALP:261

TP:6.6

Albumin:4.0

A/G ratio:1.59

Rft

Serum urea: 44-34

Serum creatinine: 0.9-0.7

Na:133-124

K:4.1-3.3

Cl:106-101

Ca:1.12-1.1

Phosphorus:2#

Ca:9.8

PT:14secs

Aptt: 28 secs

Inr:1.0

Troponin I:20.6 pg/ ml

FBS:118

Plbs

Hba1c:6.9%

Cholesterol:144

TG:147

Hdl:32

LDL:92.8

Vldl:32.4

Serology: negative

Provisional diagnosis:

Diabetic ketoacidosis with old inferior wall myocardial infarction with k/c/o type 1 diabetes mellitus since 10 years with diabetic nephropathy

Treatment:

Iv fluids ns@ 75ml/ hour

5% dextrose if grbs < 250 mg/dl

Human Actrapid insulin infusion ( 1ml +39 ml ns)@3 ml/ hour based on grbs

Tab ECOSPIRIN 75/75/10 mg / po/HS

Tab Telma 40 po od

Grbs monitering hourly

Input/ output charting

Vitals monitering 2 nd hrly