GM case A 65yr old with DKA 2° to CAP with AKI
This is an online e-log platform to discuss case scenario of a patient with their guardians permission.
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,investigations,and come up with a diagnosis and treatment plan.
Case:
A 65year old male who is a resident of thurkapallem, shop keeper by occupation came to opd with
Chief complaints:
Fever since 6days.
Breathlessness since 3days.
History of present illness:
Patient was apparently asymptomatic 10days back then he developed cold and cough with expectoration which is greenish and mucoid, no aggaravating and relieving factors. Now the expectoration has subsided.
No h/o hemoptysis.
Then developed fever 6 days back which is high grade, continuous and not associated with chills and rigor.and took medication from local RMP and got subsided.
Complaints of decreased appetite since 4 days.
Shortness of breath since 3day - grade II now increased to grade - IV since last night.
H/o nausea but no vomitting.
No h/o decreased urine output, pedal edema and loose stools.
No h/o tightness of chest.
DAILY ROUTINE:
He is a shopkeeper by occupation according to the attender his daily routine is as follows
6 am: takes a cup of tea with sugar
6:30 am: he opens his shop
If he takes a breakfast it's b/w 7-7:30 am
9 am: takes a cup of tea with sugar
11 am: bathes and goes to his shop again
12:30 pm: he eats his lunch
4:30-5:30pm: he again consumes rice
6:00 pm: takes a cup of tea with sugar
7:30 pm: takes his dinner which consist of rice
9 pm: he sleeps
PAST HISTORY
N/K/C/O DM, HTN, TB, Epilepsy, CVA, CAD.
Complaints of pain in bilateral knee joints for which he takes NSAIDS when pain increases.
H/o Surgery for right tibial fracture 5 years back
PERSONAL HISTORY
Diet : Vegetarian
Appetite : Normal before 3 days and taking only 2 meals per day and he is denying taking food.
Sleep: adequate
Bowel and bladder : Normal
Addictions : used to smoke 2 packs per day but stopped 5 years back
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
Patient conscious coherent and not co-operative.
Moderately built and nourished.
Pallor present, no icterus, cyanosis, lymphadenopathy, pedal oedema.
VITALS
Pulse : 118bpm
RR : 21 cpm
BP : 90/60 mm Hg
Temp. : 102°F
SpO2 : 96%
GRBS : high
SYSTEMIC EXAMINATION
CVS : S1, S2 hear, no thrills and murmurs
Respiratory system:
On inspection: normal chest shape,position of trachea - central
No scars,sinuses,engorged veins
Abdominothoracic type of respiration
NVBS +
decreased breath sounds in infra axillary and mammary area
Dysnea, wheeze, rales and ronchi - absent
On palpation:- all inspectory findings are confirmed on palpation.
On percussion:- right left
Infraclavicular resonant resonant
Mammary dullnote. resonant
Axillary. resonant resonant
Infraaxillary. dullnote. resonant
Suprascapular. resonant. resonant
Infrascapular. dullnote resonant
Upper, mid, lower. resonant. resonant
Interscapular
On auscultation:- normal vesicular breath sounds heard and decreased breath sounds in right inframammary,infra axillary,infrasacpular areas.
Per Abdomen: scaphoid shaped, soft and diffuse tenderness
CNS
Drowsy, arousable
Slurred speech
No neck stiffness
Cranial nerves
Tone : Normal in both the limbs
Power : 4/5 in both the limbs
Reflexes : Right Left
Biceps ++ ++
Triceps ++ ++
Supinator + +
Knee ++ ++
Ankle ++ ++
Plantar Flexor Flexor
Cerebellar examination : normal
Provisional diagnosis :
? Diabetic ketoacidosis secondary to respiratory disease.
Investigations:
Glucose monitoring chart:
Final diagnosis:
Diabetic ketoacidosis with community acquired pneumonia with prerenal AKI.
TREATMENT
2/12/2023
1) NBM until further orders
2) IV Fluids NS @ 100ml/hr
3) Inj. PIPTAZ 2.5gm IV/TID
4) Inj. LINEZOLID 600mg IV/BD
5) Tab. AZITHROMYCIN 500mg OD
6) Tab. FLUCONAZOLE 150 mg OD
7) Inj. HOMAN ACTRAPID INSULIN infusion @ 6units/hr
8) Inj. PCM 18g IV/SOS ( if temp. >= 101°F)
9) Inj. LASIX 20mg IV/BD ( if SPB >= 110)
10) IV Fluids - FRUSIDEX @ 50ml/hr
11) Tab. ATORUAS 40mg OD
12) Tab. CLOPITAB - A75/75 OD
13) Inj. PAN 40mg IV/OD
14) GRBS moniter hourly
15) Moniter BP, PR, RR, SPO2 Hourly
8:40 PM
1) Stop insulin infusion
2) Inj. HAI 6U in 500ml DNS over 5hrs
3) Inj. KCL 20mEq in 500 NS over 5hrs
Followed by
4) Inj. KCL 20mEq in 500 NS over 5hrs
5) GRBS moniter hourly
3/12/2023
1) Inj. PIPTAZ 2.25gm IV/TID
2) Inj. LINEZOLID 600mg IV/BD
3) Tab. AZITHROMYCIN 500mg OD
4) Tab. FLUCONAZOLE 150 mg OD
5) Inj. PAN 40mg IV/OD
6) Inj. PCM 1g IV/SOS ( if temp. >= 101°F)
7) Inj. LASIX 20mg IV/BD ( if SPB >= 110)
8) Inj. HOMAN ACTRAPID INSULIN infusion S/L TID according to GRBS
9) Tab. ATORUAS 40mg OD
10) Tab. CLOPITAB - A75/75 OD
11) GRBS moniter 2 hourly
12) Moniter BP, PR, RR, SPO2 2 Hourly
13) Nebulization with IPRAVENT 8th hourly and BUDECORT 12th hourly
14) Inj. KCL 20mEq in 500 NS over 5hrs
15) Tab. FENOFIBRATE 160mg OD
16) Tab. METOPROLOL 25mg OD
17) IV fluid DNS with 6u HAI + 20mEq KCl at 100ml/hr
4/12/23
1) Calcium gluconate 1 amp iv stat
2) inj 25% dextrose + 10 IU actrapid iv stat
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