DIABETIC KETOACIDOSIS.
CASE ON DIABETIC KETOACIDOSIS
October 19,
2021
GENERAL
MEDICINE
Hello all this
is G Jagadeesh,a third semester student.This E Log depicts the patient centered
approach to learning.
This
is an online E Logbook recorded to discuss and comprehend our patient's
de-identified health data shared, AFTER taking his/her/guardian's signed
informed consent.
Date of admission: October 16,2021
A 22 Year old male presented to the casuality due to
shortness of breath (SOB) and was diagnosed to be type 1 diabetes mellitus and
was on insulin therapy since 12 years.
He also complained of fever in morning just before the day of
joining and given a H/O chills at night and pain in abdomen since 2 days.
PERSONAL HISTORY
His appetite is
lost or decreased for the past two days
Follows
nonveg diet.
His bowel
habits are regular and his micturition is normal.
TREATEMENT
HISTORY
He is on insulin
since 12 years
FAMILY HISTORY
His father is diabetic
PHYSICAL
EXAMINATION
GENERAL
Pallor -
absent
icterus -
absent
cyanosis -
absent
clubbing of
fingers/toes - absent
dehydration -
mild
lymphadenopathy
absent
Oedema – absent
VITALS
temperature Afebrile on 17-10-2021 -101 but was normal on
19-10-2021.
pulse rate - 97bpm
Bp- 110/70 mm
Hg
RR - 29 cpm
SPO2 - 97%
GRBS- 100mg%
SYSTEMIC
EXAMINATION
CENTRAL NERVOUS
SYSTEM:
• Pt, conscious,
coherent, and cooperative
• Speech is normal
• no signs of
meningeal irritation
CARDIOVASCULAR
SYSTEM:
• S1, S2 +
RESPIRATORY SYSTEM:
BAE + NVBS
PROVISIONAL DIAGNOSIS
Diabetic
ketoacidosis.
INVESTIGATIONS
On 16/10/21
Hb- 12.6
TLC-11,200
LFT
Total Bilirubin - 0.85
Direct Bilirubin - O. 18
AST -10
ALT _ 10
ALP-291
Urine sugars-+ ve
urine ketone Bodies - + Ve
Urine Albumin - ++
Na-138
k - 4.5
CI - 98
On 17/10/21
Na-132
K -4.4
C I -97
On 18/10/21
p H - 7.39
pCO 2 - 26
HC03 - 15.6
pO2 - 96
T3 _0.89
T4-7.32
TSH-_1.96
Funds examination report revealed
Non-Proliferative diabetic retinopathy .
ENT
TREATEMENT
ON 16/10/2021
1.NBM Until further orders
2. IVI NS AND RL @150ml per hour
3.39ml NS +1ml HAI infusion @4ml per hour.
4.Inj pantop
5.Tab dolo 650mg
6 Temp/BP/PR/SP02 Monitoring.
Patient progress on 17/10/2021
pH-7.36
pCO2-28.6
pO2-91.2
HCO3-15.9
1.HUMAN ACTRAPID/SC
2.CEFTRIAXONE 1gm/IV/BD
3.Syp ASCORYL D Po/BD
4.Inj PANTOP40mg/IV/OD
5.Inj MVT 1 amp in NS/IV/OD
6.IVF @150ml/hr
Temp/Afebrile
BP-110/70mmHg
HR-107bpm
CVS-S1 S2 +
RESP -Nvbs
ON 18/10/2021
PR-91/min Regular
BP-120/80 mmHg
CVS S1S2 +
TREATEMENT is same
PATIENT GOT DISCHARGED ON 20/10/2021.
Comments
Post a Comment