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 .
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 )
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