DKA and HHS

August 1,2023


57 M ALTERED SENSORIUM DKA 2 DAYS , CKD 1 YEAR , PANCREATITIS 1 YAER , DIABETES 1 YAER .

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 .

CASE :

A 57 year old male patient who is a resident of nalgonda and farmer by occupation came to the casualty with altered sensorium since 2 day and Generalised weakness and uncontrolled blood  sugar levels  since 2 day.

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 1 year back . In Feb 2022 he started to talk irrelevantly and unable to recognize his family members so they went to a local Rmp who informed the patient attenders that patient is having high sugars  and got admitted here to kamineni and diagnosed him with ?DKA HHS. He got few high bp recordings at that time. He also got diagnosed with ckd and having chronic pancreatitis. He had 3 days of hospital stay and and was on HAI (10U(initially 8U)-----X-----12U). Since then he was coming to regular check up every 3 months. 

He was alright since then. But the patient thought his sugars were in control so he stopped taking insulin since 2 days ( last dose was Monday morning 8am).   On 25-7-2023  he again started to talk irrelevantly (altered sensorium)and Generalised weakness. Low grade fever which got subsided with medication (DOLO 650mg).

26-07-2023 morning at 11am went to rmp and said to have high sugars and got admitted here in our hospital.

H/o weight loss since 1 year.

H/o headache since 2 days.

No h/o vomitings , abdominal pain, sob,  palpitations.

DAILY ROUTINE : 

His occupation is agricultural worker (lemon field)
* Before 1 year(before he got diagnosedwith diabetes)- 
The patient used to eat rice 3 times a day and goes to work at 9 am and comes back to home at 5 am and watches TV and sleeps at 8 pm after having food.
* After he got diagnosed with DM 2 -
He changed his dietary habits. He eats gatka(made of jonna)(HAI 10U) as breakfast and drinks milk. And goes to work at 9am and at 1pm he has rice for lunch and at 5 pm he gets back from fields and  drinks milk and watches TV and has roti at 7pm and takes his night dose of insulin (HAI 12 U)and goes to sleep at 8 pm.

PAST HISTORY  : 

IN 2021 He had cough with sputum(muvoid) for 2-3  days and got tested positive for TB (compliant with  6 months ATT therapy). And then tested  negative for TB after 6 months of therapy.
K/c/o diabetes since 1 year on HAI (10U-----X-----12U)
Not a known case of Hypertension, asthma epilepsy, CAD,CVA

PERSONAL HISTORY :

Diet-mixed 
Appetite-normal 
Sleep-adequate 
Bowel and bladder movements-regular 
Addictions- alcohol intake and toddy drinker since 30 years daily since 1 year occasional drinker . Beedi smoker (10-15/day) and cigarette smoking occassionally stopped smoking since 1 year.

FAMILY HISTORY : 

Not significant 

GENERAL EXAMINATION : 

Patient is non coherant,conscious, cooperative 

Moderately nourished and moderately built .

No pallor,Icterus, cyanosis, clubbing lymphadenopathy, edema

VITALS : 

Temp:99.1F

BP- 120/70 mmhg

PR- 88 bpm 

RR-20 cpm

Grbs-650 mg/dl

SYSTEMIC EXAMINATION :

CNS : 

Patient is not coherant 

Speech -normal.

Cranial nerve examination-normal 

Tone-normal.

Power-5/5 in all limbs.

Reflexes:         Right              left 

      Biceps          ++                   ++

      Triceps         ++                   ++

      Supinator     ++                   ++

      Knee              ++                   ++

      Ankle              +                    +

      Plantar        flexor           flexor 


Cerebellar examination-normal.


CVS :

 S1,S2 heard and no murmurs.

RS:

BAE +, NVBS

P/A- Soft and nontender.

PROVISIONAL DIAGNOSIS : 

Diabetic ketoacidosis secondary to non compliance to insulin.

INVESTIGATIONS : 









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