A 22yrs old male came to casualty which fever since yesterday history of cough, dry nature, he had cold which was associated with chills at night and shortness of breath since afternoon 2:00 p.m.
He was apparently asymptomatic 12 years ago when he developed shortness of breath one morning after consuming sweets and was bought to casualty, after thorough investigation was diagnosed with type 1 Diabetes, had been on injection insulin 20 units iv bd, since 2 years he has been taking insulin only in the morning (without medical advice.)
on presentation GRBS was 509mg/dl
Personal history-
Appetite is normal,
Mixed diet, three meals per day, consumes meat only on weekends
Bowel and bladder habits are regular
Does not consume alcohol, smokes or illicit drugs.
He is a first year undergraduate persuing for his degree.
His daily routine consists of commuting from home to college and back home using public transportation.
He does not take part in any physical activities or sports
Has a sedentary lifestyle.
Experiences difficulty in breathing only when he is physically exerted.
past history- pt is a known case of type 1 diabetes mellitus since 10yrs of age
Has been admitted in hospital 6 times(each admission was once a year, successive years) after being diagnosed with similar complaints- difficulty on breathing, abdominal pain and vomitings.
Episodes occurred on days he had taken insulin and skipped meals, not associated with fever, infections or other stress
not a known case of HTN, BA, TB, EPILEPSY, CAD, CVD
No history of surgeries.
o/e-
lt c/c/c
PR- 98
BP- 110/80
SPO2- 99
RR- 32
GRBS- 507
CVS- S1 S1 +
RS- BAE, NVBS
P/S Soft, non tender
CNS NAD
provisional diagnosis- diabetic ketoacidosis
16/10
TREATMENT-
Nil by mouth
IVF- NS/RL 150ml/hr
Inj HAI infusion at 40ml/hr(39ml + 1ml HAI)
inj pan 40mg iv od bbf
Tab dolo 650mg po sos
GRBS- charting hourltemp/bp/pr/SpO2- charting
Soap notes day 1
Subjectivity- pt complaints of headache and vomitings
Objectively
Pt c/c/c
Bp 110/70 mm hg
Pr- 107 bpm
GRBS- 100 mg/dl
Temp 97.8 F
Cvs- S1 S2 +
Rs BAE, Nvbs
P/a soft nt
Assesment: Diabetic ketoacidosis
1) IVF - NS/RL @ 100 ml/hr
2) INJ HAI 39mlNS+ 1ml (HAI @4ml/hr)
3) Inj pan 40 mg iv od
4) T pcm 650 mg po tid
5) Syp Ascoryl 5 ml po bd
6) Tab levocitrizine 10 mg po hs
7) Inj Optineuron 1 amp in 500 ml NS IV OD
9) INJ Ceftriaxone 1 g Iv Bd
18/10/21(bed side)
ICU bed 2
Subjectivity- pt complaints of headache
Objectively
Pt c/c/c
Bp 110/60 mm hg
Pr- 88 bpm
RR 20
Grbs 274 mg/dl
Temp 97.8 F
Cvs- S1 S2 +
Rs BAE, Nvbs
P/a soft nt
Assesment: Diabetic ketoacidosis
Plan-
1) IVF - NS/RL @ 100 ml/hr
2) INJ NPH - 8am --8pm ( acc to grbs)
3) INJ HAI -8 am - 2pm -8pm
4) Inj pan 40 mg iv od
5) T pcm 650 mg po tid
6) Syp Ascoryl 5 ml po bd
7) Tab levocitrizine 10 mg po hs
8) Inj Optineuron 1 amp in 500 ml NS IV OD
9) INJ Ceftriaxone 1 g Iv Bd
ward case
Subjectivity- no fresh complaints
Objectively
Bp 120/80 mm hg
Pr- 70 bpm
RR 22
Grbs 114 mg/dl
Temp 99.8 F
Cvs- S1 S2 +
Rs BAE, Nvbs
P/a soft nt
Assesment: Diabetic ketoacidosis
Plan- continue iv fluids
inj HAI 8am(10U)---1pm(8U)---8pm(6U)
inj NPH 8pm(10U)--------8pm(6U)
inj ceftriaxone 1gm iv bd
inj optineuron od
syp benadryl po bd
Ward case
Soap notes day 4
Subjectivity- no fresh complaints
Objectively
afebrile
Bp 120/80 mm hg
Pr- 88 bpm
RR 20
Grbs 310 mg/dl
Cvs- S1 S2 +
Rs BAE, Nvbs
P/a soft nt
Assesment: Diabetic ketoacidosis( evolving) secondary to missed insulin doses/ inadequate
Diabetic retinopathy
Plan- continue iv fluids
inj HAI 8am(10U)---1pm(8U)---8pm(6U)
inj NPH 8pm(10U)--------8pm(6U)
inj ceftriaxone 1gm iv bd
syp benadryl po bd
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