202332057


Case History and Clinical Findings

PATIENT WAS BROUGHT WITH COMPLAINTS OF FEVER AND VOMITING SINCE MORNING.

 

 

THE PATIENT WAS APPARENTLY ASYMPTOMATIC TILL 1 MONTH BACK, THEN HE DEVELOPED GENERALISED ITCHING OF THE BODY AND THEN WENT TO RMP, FOLLOWING WHICH THE QUACK ADVISED TO STOP THE NIGHT DOSE OF INSULIN AND THE PATIENT STOPPED TAKING THE SAME. SINCE THE ITCHING DID NOT SUBSIDE, HE HIMSELF STOPPED TAKING MORNING DOSE OF INSULIN BUT CONTINUED TO TAKE AFTERNOON TABLET. METFORMIN 500MG PO/OD.

NOW, SINCE MORNING, HE HAS FEVER, LOW GRADE, NOT ASSOCIATED WITH CHILLS AND RIGOR, NO AGGRAVATING OR RELEIVING FACTORS.

C/O VOMITINGS , 3 EPISODES, NON-BILIOUS, NON-BLOODSTAINED, NON-PROJECTILE, WITH PREVIOUS NIGHT FOOD AS CONTENTS, ASSOCIATED WITH GENERALISED WEAKNESS.

 

K/C/O TYPE 2 DM SINCE 4 YEARS - INITIALLY USED OHA FOR 2 YEARS, THEN SHIFTED TO INJECTABLES INSULIN, 25 UNITS IN THE MORNING, AND 20 UNITS IN THE NIGHT WITH T.METFORMIN 500 MG IN THE AFTERNOON.

NOT A K/C/O HTN, TB, ASTHMA, EPILEPSY, CAD, CVA. GENERAL EXAMINATION:

THE PATIENT IS CONCIOUS, COHERENT AND COOPERATIVE.

PALLOR PRESENT. NO ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHY, GENERALISED EDEMA.

VITALS:

BP: 90/60 MM HG PR: 130 BPM

RR: 22 CPM

TEMP: 98.6 F

SYSTEMIC EXAMINATION:

CNS - NORMAL

CVS - S1 S2 HEARD, NO MURMURS, NO ADDED SOUNDS. RS - BAE+, NVBS+

P/A - SOFT, NON TENDER.

 

 

ON 22/07/2023, PATIENT WAS TAKEN FOR A DERMATOLOGY REFERAL, I/V/O GENERALISED BODY ITCHING, WHERE HE WAS DIAGNOSED AS PRURITIS UNDER EVALUATION AND WAS ADVISED:

1. LIQUID PARAFFIN L/A B/D X 2 WEEKS

2. T.TECZINE 10MG OD FOR 7DAYS

 

 

COURSE IN HOSPITAL:

PATIENT PRESENTED TO CASUALTY WITH COMPLAINTS OFFEVER AND VOMITING SINCE MORNING. THEN ON FURTHUR EVALUATION, PATIENT WAS DIAGNOSED AS DIABETIC KETO-ACIDOSIS SECONDARY TO NON-COMPLIANCE TO MEDICATION WITH RENAL AKI.

PATIENT MANAGED CONSERVATIVELY.

INITIALLY 6 UNITS OF HAI IV/STAT FOLLOWED BY 6 UNITS HAI IV/STAT.

THEN FOLLOWED BY INSULIN INFUSION TITRATED ACCORDING TO ALGORITHM 1. FOLLOWED BY INJ.HAI S/C TID AND INJ.NPH S/C BD ACCORDING TO GRBS, ALONG WITH IV ANTIBIOTICS AND IV FLUIDS.

 

DERMATOLOGY REFERAL TAKEN FOR GENERALISED BODY ITCHING AND DIAGNOSED AS PRURITIS UNDER EVALUATION, WHERE HE HAS BEEN ADVISED USE OF LIQUID PARAFFIN AND T.TECZINE.

PATIENT IS HEMODYNAMICALLY STABLE AT TIME OF DISCHARGE.

Investigation SEROLOGY - NEGATIVE RBS - 515 MG/DL HEMOGRAM -

ON 21/07/2023:

HB- 12.7 TLC-26,000

N/L/E/M/B - 92/06/01/01/00 PLT-3.2

ON 22/07/2023 HB- 12.7

TLC-26,000

N/L/E/M/B - 92/06/01/01/00 PLT-3.2

 

CUE:

ALB - + SUGARS- +++

PUS CELLS- 3-6 CELLS EPI.CELLS- 00

 

RFT -

ON 21/07/2023 UREA - 67

CREAT- 1.7

Na/K/Cl - 138/5.4/98 ON 22/07/2023 UREA - 27

CREAT- 1.1

Na/K/Cl - 133/3.3/99

 

 

 

LFT - TB- 2.05

DB- 0.65

AST- 18

ALT- 17

ALP- 338

TP- 6.6

A/G -1.09

 

 

ABG-

ON 21/07/2023- PH - 7.18

PCO2 - 9.2

PHCO3 - 3.3

PO2 - 118

ON 21/07/2023 AT 11PM PH - 7.3

PCO2 - 31.5

PHCO3 - 18.2

PO2 - 102

ON 22/07/2023 AT 5:30AM PH - 7.3

PCO2 - 34.5

PHCO3 - 18.2

PO2 - 102

 

 

URINE OSMOLALITY - 301 URINE FOR KETONE BODIES - +

 

2D ECHO - ON 22/7/23

-  TRIVIAL TR, NO MR/AR, NO RWMA, NO AS/MS, SCLEROTIC AV.

-  GOOD LV SYSTOLIC FUNCTION, DIASTOLIC DYSFUNCTION PRESENT.

 

-  NO PAH/PE, EF - 62%

 

 

USG ABDOMEN:

-  MILD HEPATOMEGALY

-  MILD URINARY BLADDER WALL THICKENING ?CYCTITIS CORELATE WITH CUE.

-  MINIMAL ASCITIS

Treatment Given(Enter only Generic Name)

1.  INITIALLY 6 UNITS HAI IV/STAT FOLLOWED BY 6 UNITS HAI IV/STAT.

THEN FOLLOWED BY INSULIN INFUSION TITRATED ACCORDING TO ALGORITHM 1. FOLLOWED BY INJ.HAI S/C TID AND INJ.NPH S/C BD ACCORDING TO GRBS

2.  INJ. CEFTRIAXONE 1GM IV/BD

3.  INJ. PAN 40MG IV/OD

4.  INJ. ZOFER 4MG IV/TID

5.  IV FLUIDS AT 100ML/HOUR.

6.  INJ. HAI S/C TID WITH INJ. NPH S/C BD, ACCORDING TO GRBS.

7.  LIQUID PARAFFIN, L/A BD X 2 WEEKS.

8.  T. TECZINE 10MG/OD X 7DAYS.

Advice at Discharge

1.  INJ HAI 6 UNITS S/C TID INJ NPH 4 UNITS S/C BD

2.  7 POINT PROFILE MONITORING AT HOME WITH GLUCOMETER.

3.  LIQUID PARAFFIN, L/A BD X 2 WEEKS.

4.  T. TECZINE 10MG/OD X 7DAYS.


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