A 48year old male with diabetic ketoacidosis 2° to alcohol(resolved)?OHA(non-compliance) with k/c/o DM,HTN

 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 patient's 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 the comment box is welcome.

Here is a case i have seen : 

48 yr old male came with cheif complaints
Pain abdomen and shortness of breath since 3days
Vomittings 4 times/day which lasted for 1 day 

HOPI:
PT was apparently asymptomatic 3 days back then he developed pain abdomen after his alcohol intake 
Pain in Rt hypochondrium and epigastric region associated with vomittings 
 
Vomiting is non bilious , non projectile , food as particle 
Shortness of breath gradual in onset and it was progressively not changing with position 

No h/o chest pain , palpitations , sweating , burning micturition , fevr , Pedro edema 

Past history :
K/c/o HTN since 6yrs 
DM since 3yrs and on medication voglibose of,0.2mg,glimiperide 2mg od,metformin 500mg od

Personal history:
Pt takes mixed diet, appetite normal,sleep adequate,bowel and bladder habits regular,alcoholic since 10yrs 

Family history:
No similar complaints in the family

Treatment history:
No known drug allergies


O/e : 
Pallor - absent , icterus - absent , lymphadenopathy - absent , clubbing - absent , cyanosis - absent. 

Afebrile on touch ,bp - 140/90mmhg , pr - 119bpm
Grbs - 443mg /dl

S/e : 
CVS - S1 S2+ 
RS - bae + , NVBS 
CNS - no FND 
P/A- tenderness at RT hypochondrium and epigastric region

Investigations - 
Hemogram 
Hb - 13.8
Tlc - 17,500
Plt - 31,000

Sr.amylase - 80

Rft - 
Urea - 50
Creatinine - 1.0
Ca- 9.4
Na - 139
K- 3.4
Cl - 106

Lft :
TB - 1.26
Db - 0.35
AST - 18
Alt - 32 
Tp - 6.1 

ECG:


USG abdomen :


Urine for ketones - positive

Abg-
 ph 6.9
po2 88,
pco2 10
st bicarb 5.2

Diagnosis dka secondary to? Alcohol
Non compliance with oha


Treatment:

Nbm till further orders
Foley's catheterization
Ivf- na(0.9%)@1000ml/hr for 3hrs next 1hr 0.9%nacl @500ml/hr,next 0.45%nacl @250ml/hr
Grbs hrly
Serum electrolytes 4th hrly
Abg 4th hrly
Inj.100meq NaHCo3 in 100ml na/iv/stat
Inj.pantop 40mg/iv/stat 
Inj.zofer 4mg/iv/stat
Inj.tramadol 1amp in 100ml na/iv/stat
I/o charting hrly
Bp/pr/Spo2- hrly
Inj.HAI 6iu/iv/stat
Inj.thiamine 1amp in 100ml ns/iv/tid 

Grbs chart:




DAY2:

C/o nausea, intermittent ,2episodes
O/e- pt is c/c/c 
Afebrile on touch 
Pr-76bpm
Bp-130/80mmhg
I/o- 5900/3950ml
CVS-S1S2+
RS-bae+, NVBS
P/A- soft, tenderness+ on deep palpation in epigastrium 
CNS-No FND

Investigations-

Urine for ketones-positive 

Serum electrolytes- 
Na - 137
K - 4.1
Cl - 103

Abg-
Ph- 7.35
Pco2- 15.7
Po2- 109
Hco3- 8.6
St.Hco3- 13.4

HbA1c- 7.3%

CUE- 
Sugars- +
Pus cells- 2-4
Epithelial cells- 2-3
Albumin- Nil 

Treatment-

Nbm till further orders
Inj HAI(1ml ,40IU + 39ml NS) @6ml/hr,to maintain grbs<250mg/dl, increase/decrease 1IU/hr if increase in grbs
Grbs hrly and inform pg
Serum electrolytes 4th hrly
Inj.pantop 40mg/iv/stat 
Inj.zofer 4mg/iv/tid
Inj.tramadol 1amp in 100ml na/iv/stat
I/o charting hrly
Bp/pr/temp- hrly
Inj.HAI s/c premeal after informing pg
Inj.thiamine 1amp in 100ml ns/iv/tid 

DAY3:

No fresh complaints
O/e-pt is c/c/c 
Afebrile 
Pr-80bpm
Bp-120/70mmhg
I/o- 3050/3100ml
CVS-S1S2+
RS-bae+, NVBS 
P/A- soft,non-tender, passed stools 

Investigations-

Fbs-184
UKB- positive 
ABG- ph- 7.39
          Pco2-20.7
          Po2-93.3
          Hco3-12.3
          St.Hco3-16.3

Treatment-

Allow soft diet 
Ivf-NS,RL @50ml/hr
Inj.pantop 40mg/iv/od
inj.zofer 4mg/iv/sos
Inj.thiamine 1amp in 100ml NS/iv/tid
I/o charting hrly
Bp/pr/temp hrly
Grbs 6th hrly premeal
Inj.             8am          2pm           8pm
Regular    10IU          10IU           10IU
NPH         10IU              -               10IU

Grbs chart :




DAY 4:

No fresh complaints
O/e-pt is c/c/c 
Afebrile 
Pr-82bpm
Bp-120/80mmhg
I/o- 3050/3100ml
CVS-S1S2+
RS-bae+, NVBS 
P/A- soft,non-tender, passed stools 

Investigations-

Sr.potassium - 3.4mmol/L

Treatment-

Strict diabetic diet 
Inj.pantop 40mg/iv/od
inj.zofer 4mg/iv/sos
Inj.thiamine 1amp in 100ml NS/iv/tid
I/o charting hrly
Bp/pr/temp hrly
Grbs 6th hrly premeal
Inj.                8am      2pm     8pm
Regular        12IU      10IU     10IU
NPH             12IU         -         12IU
(First load NPH then regular)
Syp.potchlorin in 1glass of water for only 2days

Grbs chart :


 

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