1801006158 SHORT CASE

 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"


25 YR OLD MALE WITH CHEST PAIN, VOMITINGS AND SOB 


25/M painter by occupation who was apparently asymptomatic 9 years back,

Patient c/o blurring of vision for which he went to local hospital used medication but his blurring of vision(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 apetite, 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.. 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 came with c/o fever high grade associated with chills and rigors, Nausea, Vomitings , constipation

And c/o neck pain

No c/o chest pain palpitations , syncopal attacks 

No meningeal signs 


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


Outside 24hr urine proteins 3920mg/day 


On presentation his vitals are 

Afebrile 

BP - 110/80 mmhg

PR - 86bpm

Spo2 - 100 at RA

CVS - S1S2+

RS - normal vesicular breath sounds heard 

On HAI infusion according to Algorithm 1

Not a k/c/o HTN / Asthma / CAV / CAD


Personal history :

Sleep: adequate 

Appetite: normal 

Diet: mixed

Bowel and bladder movements: normal 

Addictions: none 


Family history : 

No similar complaints in family 


General examination :

Patient Is conscious, coherent, cooperative moderately built and well nourished 

pallor - Absent 

icterus - Absent

clubbing - Absent

cyanosis - Absent

lymphadenopathy - Absent

Edema - Absent

Vitals:

TEMP-96.5 F

PR-82/MIN

RR-14/MIN

BP-110/70MMHG

SPO2-99% AT ROOM AIR

GRBS-197MG%. 

Systemic examination :

CVS - S1S2 present, no murmur

RS - Bilateral air entry present, trachea central in position 

CNS - Higher mental functions intact 

P/A - Soft, non tender


Clinical images with investigation





ECG



2D ECHO -


No rwma 
NoAs / Ms 
Good left ventricular systolic function nd diastolic function 





Blood and urine - 

ABG _ pH  7.19   pco2 12 mmHg  HCO3 - 9.7 Meq 


Hb - 7 gm/dl 
Pcv - 47 
TLC- 11,000mm3 
RBC 5.7 cells / mm3 
Urea -44 meq 
Serum creatinine - 0.9 meq 
S .Na- 133 meq 
S . potassium - 4.1 meq 
Serum chloride - 106 meq 
SGPT - 25
 SGOT - 27

CUE  
Albumin +++
Ketone body ++
Sugar + 



Diagnosis :

DIABETIC KETOACIDOSIS(RESOLVED) WITH OLD INFERIOR WALL MI WITH K/C/O TYPE I DM SINCE 9YRS WITH DIABETIC NEPHROPATHY 

 Treatment :

* IV FLUIDS NS@75ML/HR

 5% DEXTROSE IF GRBS <= 250MG/DL

* HUMAN ACTRAPID INSULIN INFUSION ( 1ML +39 ML NS) @ 3ML/HR BASED ON GRBS 

* TAB ECOSPRIN GOLD 75/75/10MG PO HS  

* GRBS MONITORING HOURLY

* STRICT I/O CHARTING.

* VITALS MONITORING 2ND HRLY.


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