17 year old girl with diabetic ketoacidosis

 17 YEAR OLD GIRL WITH DIABETIC KETOACIDOSIS

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A 17 year old girl , studying 10th class, hailing from Janapahad near Miryalaguda , presented to the OPD with chief complaints of fever and vomitings since yesterday ( 05/11/22 ) morning .

History of presenting illness : The patient was apparently asymptomatic 7 years back . In 2015 ,  she got fever with 4-5 episodes of vomitings for which was taken to Nilofer where she was admitted for 1 month , they performed blood sugar tests and she was then diagnosed with type - 1 diabetes mellitus . 

In 2018 , she again had 2 episodes of vomitings with very high sugar levels when checked with the glucometer , she was admitted in KIMS Narketpally for 5 days .

Now again in 2022 , she had missed her morning dose of insulin and morning breakfast yesterday ( 05/11/22 ) as she woke up late . She presented to the OPD with fever and had 8 episodes of vomitings which were non bilious , non projectile with food as contents . She also complained of SOB for a very brief period on lying down , she was taken to a local doctor where when checked  the blood sugars were 550 mg/dl for which insulin dose was given . She was then referred to KIMS Narketpally .

She also complains of excessive thirst when she has high sugar levels .

Past history : The patient was diagnosed with type 1 diabetes mellitus 7 years back .

She is not a K/C/O HTN , asthma , TB , thyroid disorders , epilepsy.

Personal history : The patient wakes up between 7-7:30 am in the morning, takes her insulin dose, has her breakfast. She goes to school at 9 am by walking, has her lunch at school itself and returns home at 5 pm . She does her homework and studies till 9 pm, then takes her insulin dose, eats dinner and sleeps by 9:30 pm .

Diet - mixed ( consumes chicken weekly once )

Appetite - normal

Sleep - adequate ( from 9:30 pm to 7:30 am )

Bowel and bladder movements - regular

Family history :

The patient's paternal grandfather ( expired ) is diabetic . The maternal grandfather is diabetic since 8 years and maternal grandmother is diabetic since 4 years , both of them are on oral hypoglycemic drugs since then .

Treatment history :

The patient is on insulin therapy since 7 years .

She takes 10 units of insulin ( 5 units of IPH insulin and 5 units of HAI ) twice daily , once before breakfast and once before dinner .

For the first 6 months of therapy , she has been injecting around the umbilicus , later on she has been injecting into her deltoid muscle .

Everyday she checks her blood sugar levels with glucometer in the morning and evening .

She has been having spikes in her sugar levels all along .

General Examination : The patient is conscious, coherent and cooperative, well built and nourished .

Pallor, icterus, cyanosis, clubbing, pedal edema and generalised lymphadenopathy are absent .

VITALS :

06/11/22 :

Temperature - afebrile

BP - 110/70 mm Hg

HR - 90bpm

RR - 18 cpm

07/11/22 :

Temperature - afebrile

BP - 110/70 mm Hg

HR - 80 bpm

RR - 18 cpm

08/11/22 :

Temperature - afebrile

BP - 100/70 mmHg

HR - 100 bpm

RR - 18 cpm

Systemic Examination : 

CVS : 

On palpation ‐

• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line. 

• JVP was normal 

• No precordial bulge 

• No parasternal heave

On auscultation ‐ S1, S2 heard , no murmurs 

RS :

On inspection ‐

• Chest is bilaterally symmetrical 

• Expansion of chest: Equal on both sides

• Position of trachea: Central

• No visible scars, sinuses, pulsations

On palpation : 

• Expansion of chest was equal on both sides. 

• Position of trachea: Central

• Tactile Vocal Fremitus: resonant note was felt.

On percussion: all lung areas were resonant 

On auscultation : 

• Bilateral air entry was present, normal vesicular breath sounds were heard. 

• Vocal resonance: resonant in all areas

P/A : soft, non tender, no organomegaly, no distension, bowel sounds heard.

CNS : The patient is well oriented to time, place, person.

Higher mental functions are intact.

Cranial nerve examination :‐

All cranial nerves are intact and functioning. 

Motor System Examination :‐

• Normal bulk in upper and lower limbs

• Normal tone in upper and lower limbs

• Normal power in upper and lower limbs

• Gait is normal 

. Reflexes are normal .

Sensory System Examination :‐

Normal sensations are felt in all the dermatomes.

No cerebellar signs .

No meningeal signs.

Investigations :

Provisional Diagnosis : Diabetic Ketoacidosis

Treatment : 

06/11/22 :

1) Inj. Human Actrapid Insulin infusion 4 ml/hr for 5 hrs , then 2 ml/hr for the next 5 hrs .

2) IV fluids - NS /RL /5% dextrose at 100 ml/hr

3) Inj. Pantop 40 mg IV OD

4) Inj. Zofer 4 mg IV BD

5) Inj. Monocef 1 gm IV BD

6) Inj. Piptaz 4.5 gm IV TID

7) Inj. Neomol 1 gm IV SOS ( if temperature > 101 F )

07/11/22 :

1) Inj. Human Actrapid Insulin infusion 4 ml/hr for 5 hrs , then 2 ml/hr for the next 5 hrs .

2) IV fluids - NS /RL /5% dextrose at 100 ml/hr

3) Inj. Pantop 40 mg IV OD

4) Inj. Zofer 4 mg IV BD

5) Inj. Monocef 1 gm IV BD

6) Inj. Piptaz 4.5 gm IV TID

7) Inj. Neomol 1 gm IV SOS ( if temperature > 101 F )