Diabetic ketoacidosis secondary to acute gastroenteritis

This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs.

 I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, and investigations, and come up with a diagnosis and treatment plan

A 49 Year old male, autodriver by occupation , came to casualty on 24th June 2023 with chief  complaints of

CHIEF COMPLAINTS:

Giddiness since one week and pain and weakness in the right lower limb since one week.


HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 days ago then he developed Giddiness which is sudden in onset, gradually progressive.

C/o Vomitings 4-5 episodes, watery, non-projectile, bilious with food particles on the same day of giddiness. Not Blood tinged. Relieved with medications.


C/o Loose stools: 4-5 episodes, watery, non blood stained, non-mucoid, non- foul smelling since the day of joining.


C/o Pain in Right side of body along with weakness of Right lower limb, one week back,


C/o Facial puffiness since one week.


C/o pain on the forehead radiating to right side of the face.


No C/o Fever, pain abdomen, decreased urinary output, pedal edema.


DAILY ROUTINE

The patient is a Farmer and Autodriver

  • 4AM: Wakes up and goes to farm(occasionally)
  • 8AM: Drinks Tea
  • 9AM: He eats Rice
  • 10AM- 1PM: Goes for driving Auto
  • 1PM: Eats Lunch- Rice with dal 
  • 2PM: Takes a nap and wakes up at 4PM
  • 4PM: Goes for driving Auto
  • 6:00: Tea and soft drink
  • 8PM: Dinner
  • 9PM: The patient goes to bed 
   PAST HISTORY :


Patient went to a hospital 1 month back with C/o headache, giddiness and was diagnosed as hypertension and put on medications.


Patient is a known case of  DM II since 13 years and is on medication.(GLIMI-M4 Forte PO/OD)


The patient was operated for haemorrhoids 20 years back


 Not a known case of CAD, Bronchial asthma, Epilepsy, TB.

PERSONAL HISTORY

DIET - Mixed

APPETITE- Decreased since one week

SLEEP - Adequate

BOWEL AND BLADDER- Regular

ADDICTIONS -  alcoholic since 10 years.Stopped consumption 6 years back.

Chewing tobacco since 20 years.


FAMILY HISTORY

No relevant family history 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative; well oriented to time,place and person  moderately built and well nourished.

No icterus, clubbing, cyanosis, lymphadenopathy, edema.


VITALS:

  1. BP: 120/80 mmHg
  2. PULSE : 82 Bpm
  3. RESPIRATORY RATE: 14cpm
  4. TEMPERATURE: Afebrile
SYSTEMIC EXAMINATION:

1. RESPIRATORY SYSTEM : B/L Air entry Present, Normal vesicular breath sound+


2. CARDIOVASCULAR SYSTEM: S1, S2 heard, no murmurs.

3. ABDOMINAL EXAMINATION : Soft, Non- Tender

4. CNS - No Focal neurological deficits


Investigations:

Random blood sugar 
Hemogram
Blood urea
 serum creatinine
serum elctrolytes
complete urine examination 
 Abg
 ketone bodies 
 colour doppler
 chest x ray
 Mri

PROVISIONAL DIAGNOSIS:

Diabetic Ketoacidosis secondary to ? Acute Gastroenteritis with lateral medullary syndrome


TREATMENT

Intravenous fluids normal saline
Inj. PAN 40mg IV/OD 
Inj. BUSCOPAN IM/ SOS
Tab. TELMA 40mg PO/ OD
Monitor GRBS Hourly

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