Medical Logbook by Raveela. N

 Case of 21/M Viral Pyrexia associated with DKA

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-centred online learning portfolio and your valuable comments on comment box are welcome.
Name : Raveela 
Roll no : 95
Batch  :2017
Case Presentation
Cheif complaints: 21/M  resident of miryalaguda was bought to the casuality with  complaits of Fever since :5 days, c/o decreased appetite:7 days c/o vomiting since 1 day, c/o sob since morning
HopI: Patient was apparently asymptomatic 5 days back  then he developed fever which was insidious in onset, high grade, intermittent a/w chills and relieved on medication . Patient had H/o 1 episode of vomiting 1 day back which was non- bilious,non-projectile.
No h/o any burning micturition, throat pain, cold,cough.

Not a k/c/o HTN,DM, CAD, asthma, TB, epilepsy.

Personal History:
Patient has mixed diet with normal appetite and adequate sleep. 
he has normal bowel movements and bladder filling. 
No addictions. 

No significant family history or allergic history. 

General Examination:
Patient is c/c/c ,moderately built and moderately nourished. 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema
VITALS
BP: 140/90 MMHG, 
PR: 120bpm 
Temp: 98.2°F, 
RR: 40 CPM, 
SPO2: 99% 
Systemic Examination
RS: BAE+,NVBS heard
CVS: S1 ans S2 heard. No murmurs.No thrills
P/A: soft and non-tender. 
CNS: No focal deformities. 
Investigations:
Haemogram:
Hb: 8.2
TLC: 15800
N:89
L:6
PCV: 30
Mcv:63.7
MCH:17.4
MCHC:27.3
PLC:3.37
RBC:4.71
2) Liver Function Test

3) Complete urine examination

4) Random blood sugar:194mg/dl

5) Blood Urea




6) Serum Creatinine:

7) Urine for ketone bodies

8) ABG@2pm


9) Serum electrolyte:@2pm


Serum electrolyte @10 pm
10)Chest xray PA view:


 Provisional Diagnosis:
DIABETIC KETOACIDOSIS
With denovo detected diabetes mellitus with viral Pyrexia  under evaluation. 
TREATMENT:
On DAY-1
1)NBM till further orders
2)IVF 3lit NS @500ml/hr(in 3hrs) f/by IVF NS@250ml/hr 
3)Inj. HAI 4IU IV/stat f/b Inj. HAI 1ml (40IU) in 49ml NS @ 4ml/hr(untill ABG correction)
4)Inj. PAN 40mg IV/OD
5)IVF 5%DEXTROSE @50-100ml/hr(when GRBS <150) [increase/decrease acc. to GRBS]
6)Inj.OPTINEURON 1amp in 100ml NS/IV/OD 
7)GRBS monitoring hourly
8) Strict i/o. Monitoring
9)Inj. KCl 2amp in 500ml NS @100ml/hr

On DAY-2 :
SOAP NOTES:

S: 
No fever spikes,sob decreased ,no fresh complaints
O:
BP-110/90mm hg
PR-74bpm
CVS:S1S2 heard
Rs:BAE +,NVBS
P/A:soft
A:
HAGMA, DKA
Hemogram:


ABG @ (1am) 

@8AM

@3PM

SERUM ELECTROLYTES: @8am

@5pm
  


@10:30pm

P:


DAY-3 :
S: Patient sob decreased,No fresh complaints

O: BP 110/80 mm hg
PR: 70 bpm
CVS: s1 s2 heard 
RS: BAE+ NVBS 
P/A: soft 
ABG@6.30AM

Serum electrolyte @ 8Am


Assesmemt : over night patient grbs around 290 mg/dl and Patient anion gap is reducing day by day and subjectively feeling better .

Plan of care : Look for today morning abg and stop iv insulin infusion and start him on NPH and HAI

Brief  case history by Dr. Ranjith. 
https://ranjith119.blogspot.com/2021/10/diabetic-ketoacidosis-with-denovo.html










Popular posts from this blog

55 yr old male with abdominal pain and chest pain , shortness of breath

Image
  55 yr old male with abdominal pain, chest pain, shortness of breadth.  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 a series of inputs from an 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 and your valuable inputs in the comment box is welcome N. Raveela Roll. No :95 55yr old male came to the opd with cheif complaints of abdominal pain 5 days and chest pain 2 days.  HOPI:  Patient was apparently asymptomatic 5days back ,then he consumed alcohol for 3 days without taking proper food and started developing abdominal pain ,which is sudden in onset , dragging type , gradually progressive ,aggrevated by alcohol intake and relieved ...
Read more

Medicine Case Discussion

  Online Blended Bimonthly assignment towards summative assessment for the month of May 2021 Pulmonolgy 1) A 55yr old female with Shortness of breath,pedal edema and facial puffiness.  A) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? Ans:At the month of january that year during which time she was working in a paddy field. For the next 8 years the patient has suffered from similar episodes of SOB every year each lasting aproximately 1 week For the past 12 years she has been having an yearly episodes now lasting around a month again around january. Until her latest episode the SOB was of grade II Her latest episode of shortness of breath started 30 days ago, her SOB was insidious in onset and gradual in progression. Initially the SOB occurred on exertion and was relieved upon rest. From 2 days ago she started having SOB e...
Read more

CKD with ADPKD

Image
  Case of 55 yr /M with CKD with Autosamal dominant PKD.  Cheif complaints :  *pedal edema   and facial puffiness since 3 months.  * sob since 2months HOPI: Patient was apparently asymptomatic 3 months back then he developed  pedal edema   first observed at ankle later progressed upto the knee (pitting type) along with facial puffiness in the same time period.  He also complained of SOB since 2 months Initially it was  observed on doing his regular work(Granite cutting) and  then aggrevated even on walking (Grade 2) not relieved on medication.  The patient had a history of occasional cough on and off, usually productive, since 2 months while doing his work which subsided on  medication.  No h/o blood vomiting, fever and burning micturation.  He was taken to a hospital in Nalgonda where he was asked to get usg abdomen done and diagnosed with poly cystic kidney disease and referred to KIMS for further evaluati...
Read more