A 19 year old male with DKA


A 19 year old male with DKA


Viharika Vupputuri 

Roll no- 144

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. 

Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.

This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.

I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.


CASE PRESENTATION

A 19 year old male came to the OPD on 24th March with the chief complaints of 

a) Vomiting since 2 days
b) Shortness of breath on 24th of march

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic one and half ago, then he developed polyuria, nocturia, polydypsia one and half year ago, was diagnosed as Diabetic type 1 MISC post COVID and during the hospital stay, on day 5 he went to coma for 7 days, then recovered and discharged after 20 days.


About 4 months ago, he developed vomitings, which was non projectile type , food and water as content, DKA 2° to DM 

Now the patient presented with vomiting 10 episodes in 2 days which subsided after the patient admitted in the hospital. Non-projectile type of vomiting associated with nausea and abdominal discomfort and had food particles as contents which is not blood stained.

History of outside food consumption.

Shortness of breath was insidious in onset.

No h/o loose stools, fever, cold, cough, abdominal pain and burning micturation.

PAST HISTORY

Not a known case of Hypertension , Asthma , Epilepsy , Tuberculosis.

PERSONAL HISTORY

Daily routine

8am - Wakes up
9am- Breakfast
10am to 1pm goes to college
2pm- Lunch
3pm to 6pm- Goes out with friends
8 pm- Dinner
9pm- Sleep

Diet - Adequate
Appetite - Normal
Bowel and bladder movements - Regular
Sleep - Adequate
Addictions - No addictions
Allergies - No allergies

FAMILY HISTORY

Insignificant.

TREATMENT HISTORY

Insulin injections 

Morning -  52 units 

Afternoon - 26 units 

Night - 52 units





GENERAL EXAMINATION

Patient was conscious, coherent and cooperative examined in a well lit room.
Patient is moderately built and well nourished.

Weight: 75 kgs
Height: 167cms
BMI: 27.7

Pallor - Absent
Icterus - Absent 
Clubbing - Absent
Cyanosis - Absent 
Lymphadenopathy - Absent 
Edema - Absent




VITALS 

Temperature - Afebrile
Blood pressure - 120/80 mmHg
Respiratory rate - 18 cpm
Pulse rate - 76 bpm
SpO2 - 96% on RA
GRBS - 157 mg/dl

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM

Bilateral air entry present

CARDIOVASCULAR SYSTEM

S1, S2 sounds heard 
Murmurs - Not heard

CENTRAL NERVOUS SYSTEM - NAD


ABDOMEN

Inspection

Shape of the abdomen - Distended
Umbilicus - transverse slit like
All quadrants are moving equally with respiration
Skin over the abdomen - Normal
Superficial veins - Not visible





Palpation

No rise in temperature
Tenderness in all quadrants - Absent
Light palpation- all quadrants are normal, no pain
Deep palpation- lipodystrophy felt on right iliac fossa 

Liver - Not enlarged

Spleen - not enlarged

Kidneys - bimodal palpable kidneys

Percussion

No shifting dullness

Auscultation

Bowel sounds - heard
No bruit

INVESTIGATIONS  

                     SERUM ELECTROLYTE


                            BLOOD SUGAR 


                             BLOOD UREA


                 GLYCATED HAEMOGLOBIN




                   LIVER FUNCTION TESTS


                             PHOSPHORUS


                       SERUM CREATININE


                BLOOD SUGAR - FASTING


                     KETONE BODIES


              COMPLETE BLOOD PICTURE


                                  ECG



USG ABDOMEN

Impression - Grade 1 Fatty liver

PROVISIONAL DIAGNOSIS

Diabetic ketoacidosis 2° to ? inadequate insulin, ?Acute Gastroenteritis.

TREATMENT

IVF - 20NS 20RL @100ml/hr
Inj.HUMAN ACTRAPID 40U in 39ml NS @ 5ml/hr
Inj.PANTOP 40 mg IV / OD
Inj.ZOFER 4 mg IV / TID
Inj.NEOMOL 1g IV / SOS
Tab.DOLO 650 mg PO / TID
Inj. 5%dextrose  50ml/hr
Inj.MONOCEF 1gm IV / BD
Strict GRBS , BP Charting









Comments

Post a Comment

Popular posts from this blog

Medical assignment

Image
MEDICINE ASSIGNMENT 31st May 2021 Medicine assignment for the month of May 2021 Viharika Vupputuri  Roll no - 144  I   have been given the following cases 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 diagnosis and coem up with a treatment plan. This is the link of questions asked regarding the cases:   http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1       Below are my answers to the Medicine Assignment based on my comprehension of the cases.    FIRST CASE :   PULMONOLOGY    A 55 year old female with shortness of breath, pedal edema and facial puffiness.   https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html     1) What is the evolution of the symptomatology in ...
Read more

A 20 YEAR OLD MALE CAME WITH FEVER AND VOMITING

Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. A 20 year old male driver came to opd wit complaints of  1) Fever since 2days  2) Vomiting since 6hrs HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic 2 days back then he developed fever which is not associated with chills and rigors and relieved with medication. No diurnal variation. Vomiting since 6hrs with 3 episodes and content as food material, blood tinged, non bilious, non projectile. He skipped 1 dose on insulin yesterday evening. No h/o loose stools, pain...
Read more

36 year old male with angioedema

Image
 36 year old male with angioedema Viharika Vupputuri  Roll no- 144 This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent.  Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs. This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome. I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation. CASE PRESENTATION  A 36 yr old male patient who is a watchman in a government hospital was admitted at 4AM on 12/01/2022 in the OPD with the chief complaints of  1) Discomfort of the throat...
Read more