Diabetic ketoacidosis case

 General Medicine E-log 

Chief complaints:

A 13 year old female patient was brought to the hospital in a drowsy state with history of fever and episodes of vomiting.

Date of admission: 11/10/22

History of present illness: 

The patient was apparently asymptomatic 3 months ago when she felt weak and developed fever after returning from school for 2-3 consecutive days. She was taken to a hospital in Miryalaguda where they found her blood sugar levels were around 350 mg/dl, she was diagnosed with type 1 diabetes mellitus. She was started on insulin injections (initially 12 and 18 units which was increased to 18 and 16 units after a week) which she took in 2 doses, one in the moring and one at night for the following 3 months. On 10th of October 2022, she left her house without taking her moring dose of insulin as she was running late for school. When she returned home at 6:00 pm she felt very weak and soon she developed fever. She had vomited thrice when she was in school and thrice at home. She was taken to an RMP who put her on saline. Her condition did not improve and she vomited again following which she was taken to a local hospital in altered sensorium at 1:00 AM. Her blood sugar was at 311 mg/dl and she was put on I.V. fluids. She had abdominal pains and shortness of breath and was rushed to KIMS, Narketpally in an ambulance at 3:00 AM as suggested by the doctors at the local hospital.

History of past illnesses:

Patient is a known case of type 1 diabetes mellitus since 3 months for which she is taking insulin injections.

She is not a known case of HTN, TB, epilepsy, asthma, CVD or CVA.

Personal history:

Occupation: student

Appetite: increased 

Sleep: adequate 

Bowel movements: normal

Bladder: polyuria and nocturia

Addictions: no addictions

Drug history:

She is taking biphasic isophane insulin injections for type 1 DM (moring dose 18 units and evening dose 16 units).

Family history:

No significant family history.

General examination:

Patient is conscious, coherent and co-operative.

No pallor, icterus, cyanosis, clubbing, koilonychia, generalized lyphadenopathy or edema was seen.

Vitals:

BP: 100/80 mmHg

PR:  120 bpm

RR: 28 per min

Temperature: afebrile 

GRBS: 88 mg/dl

SpO2: 100% at RA

Systemic Examination:

CNS:
Speech: normal
No signs of meningeal irritation
Motor & sensory system: normal
Cranial nerves: intact
                    

Reflexes: present

CVS:

S1, S2 were heard

No Murmurs
No thrills

Respiratory system:
Position of Trachea: central
BAE: present
NVBS heard
No added sounds

Per Abdomen:
Soft, non tender
Hernial orifices are normal
No palpable masses
Bowel sounds heard

Provisional diagnosis: Diabetic ketoacidosis 

  

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