DKA
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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 diagnosis and treatment plan.
With invaluable information from
https://nikithaedam48.blogspot.com/2021/06/18-year-old-malefrom-miryalagudawho-is.html?m=1
"H/o admission to our hospital in July i/v/o jaundice. Had high sugars and HbA1c was 8.5, diagnosed with type 1 DM."
He went into coma soon after admission and everyone nearly lost all hopes for a week before he suddenly stepped out of his coma which was thought to be a hepatic coma although Reyes syndrome (Arun intern's inputs) had been a close differential
Unit 6 Admission
The patient is an 18y/o male. He came to the casuality with the chief comlaints of
1. Vomitings since last night
2. SOB since last night
3. Chest pain since last night
The patient was apparantly asymptomatic 1 day ago. After eating in the afternoon, he had am episode of vomiting. Non projectile, non bilious, content food and blood stained. During the night he had 2 more episodes of vomiting, non projectile, non bilious, non blood stained. He also had chest pain and SOB along with vomitings during the night for which he was brought to the casuality in the morning.
H/o admission to our hospital in July i/v/o jaundice. Had high sugars and HbA1c was 8.5, diagnosed with type 1 DM. Taking Mixtard insulin 15U in the morning and 15U in the evening.
O/E
Pt is conscious
Moderately built and nourished
Afebrile
No icterus, cyanosis, lymphadenopathy, clubbing, lower limb pitting edema.
BP 110/80 mmHg
PR 72 bpm
RR 13 cpm
SpO2 97% in room air
GRBS 400 mg/dl
CVS
S1 S2 heard
No thrills and murmurs
RS
Dyspnoea +
Wheeze -
Trachea central
Breath sounds vesicular
P/A
Soft, diffuse abdominal tenderness with more pain in the epigastrium and and R hypochondrium
CNS
Pt is conscious
No signs of neck stiffness
Power 5/5 in all 4 limbs
Pupils NSRL
Reflexes are all +2
Prov Diagnosis
DKA
SOAP NOTES DAY 1
ICU 3rd BED
S
Pt is C/C/C
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 120/80 mmHg
PR 92 bpm
RR 17 cpm
SpO2 98 at room air
A
DKA with k/c/o Type 1 DM
P
1. HAI infusion 40 IU in 40ml infusion at 6ml/hr
2. Inj CEFTRIOXONE 1gm IV BD
3. Inj OPTINEURON 1 amp in 100 ml NS IV OD
4. Temp charting
5. GRBS charting
6. BO, PR, RR, SpO2 monitoring
SOAP NOTES DAY 2
ICU 3rd BED
S
Pt is C/C/C
Diffuse pain abdomen
One fever spike
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Temp 100.1 F
BP 110/70 mmHg
PR 86 bpm
RR 15 cpm
SpO2 98 at room air
Na 138
K 3.9
Cl 98
pH 7.405
pCO2 21.4
pO2 -
HCO3 17.4
GRBS
8am 196mg/dl
2pm 224mg/dl
8am 250mg/dl
A
DKA with k/c/o Type 1 DM
P
1. HAI infusion 40 IU in 40ml infusion at 6ml/hr
2. Inj CEFTRIOXONE 1gm IV BD
3. Inj OPTINEURON 1 amp in 100 ml NS IV OD
4. IVF NS 100ml/hr
5. Inj PAN 40mg IV OD
6. Inj ZOFER 4mg IV TID
7. Temp charting
8. GRBS charting
9. BO, PR, RR, SpO2 monitoring
8 am ABG
pH 7.35
pCO2 14.7
pO2 110
HCO3 12.9
SOAP NOTES DAY 3
ICU 3rd BED
S
Pt is C/C/C
Reduced pain abdomen
One fever spike
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Temp 99 F
BP 110/70 mmHg
PR 90 bpm
RR 13 cpm
SpO2 98 at room air
Stools not passed
pH 7.415
pCO2 22.2
pO2 -
HCO3 17.8
8pm serum K 3.7
GRBS
8am 196mg/dl
2pm 271mg/dl
8am 164mg/dl
A
DKA with k/c/o Type 1 DM
P
1. HAI infusion 40 IU in 40ml infusion at 6ml/hr
2. Inj CEFTRIOXONE 1gm IV BD
3. Inj OPTINEURON 1 amp in 100 ml NS IV OD
4. IVF NS 100ml/hr
5. Inj PAN 40mg IV OD
6. Inj ZOFER 4mg IV TID
7. Temp charting
8. GRBS charting
9. BO, PR, RR, SpO2 monitoring
SOAP NOTES DAY 4
AMC Patient
S
Pt is C/C/C
One fever spike
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Temp 101 F
BP 110/80 mmHg
PR 92 bpm
RR 13 cpm
SpO2 98 at room air
pH 7.476
pCO2 27.3
pO2 96.5
HCO3 22.7
Na 138
K 3.1
Cl 98
TB 1.84
DB 0.5
AST 11
ALT 09
ALP 191
Protein 5.4
Alb 3.3
A/G 1.61
A
DKA with k/c/o Type 1 DM
P
1. Insulin bridging
2. Inj CEFTRIOXONE 1gm IV BD
3. Inj OPTINEURON 1 amp in 100 ml NS IV OD
4. IVF NS 100ml/hr
5. Inj PAN 40mg IV OD
6. Inj ZOFER 4mg IV TID
7. Temp charting
8. GRBS charting
9. BO, PR, RR, SpO2 monitoring
SOAP NOTES DAY 5
AMC Patient
S
Pt is C/C/C
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 110/80 mmHg
PR 92 bpm
RR 13 cpm
SpO2 98 at room air
Na 138
K 3.9
Cl 99
A
DKA with k/c/o Type 1 DM
P
1. IVF NA,RL at 100ml/hr
2. Inj HAI s/c 8am 2pm 8pm
3. Inj NPH s/c 8am 2pm 8pm
4. Temp charting
5. GRBS charting 8am 1pm 8pm 2am
6. BO, PR, RR, SpO2 monitoring
SOAP NOTES DAY 6
AMC Patient
Endocrinology option taken. Adviced thyroid profile and long acting BASALOG insulin h/s 10 units. Review USG (pancreas obscurerd by diffuse bowel gas).
S
Pt is C/C/C
No fever spikes
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 110/60 mmHg
PR 92 bpm
RR 16 cpm
SpO2 98 at room air
Na 149
K 3.5
Cl 100
Hb 11.4
TLC 4100
Plt 1.67 lakh
N 35
L 51
M 9
E 5
B 0
A
DKA k/c/o Type 1 DM with viral pyrexia with theombophlebitis
P
1. IVF NA,RL at 100ml/hr
2. Inj HAI s/c 8am 2pm 8pm
3. Inj NPH s/c 8am 2pm 8pm
4. Temp charting
5. GRBS charting 8am 1pm 8pm 2am
6. BO, PR, RR, SpO2 monitoring
SOAP NOTES DAY 6
http://mahithguduri63.blogspot.com/2021/10/dka.html
AMC Patient
S
Pt is C/C/C
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 120/70 mmHg
PR 87 bpm
RR 16 cpm
SpO2 98 at room air
Na 142
K 3.5
Cl 101
Hb 11.4
TLC 4200
Plt 1.60 lakh
N 28
L 58
M 19
E 5
B 0
GRBS
8am 298 (20A 20N)
10 am 300
2pm 256 (26A)
4pm 313
8pm 283 (20A 20N)
A
DKA k/c/o Type 1 DM with viral pyrexia with theombophlebitis
P
1. IVF NA,RL at 100ml/hr
2. Inj HAI s/c 8am 2pm 8pm
3. Inj NPH s/c 8am 2pm 8pm
4. Temp charting
5. GRBS charting 8am 1pm 8pm 2am
6. BO, PR, RR, SpO2 monitoring
SOAP NOTES DAY 7
http://mahithguduri63.blogspot.com/2021/10/dka.html
AMC Patient
S
Pt is C/C/C
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 120/70 mmHg
PR 87 bpm
RR 16 cpm
SpO2 98 at room air
Hb 11.8
TLC 4200
Plt 1.60 lakh
N 28
L 58
M 19
E 5
B 0
GRBS
8am 316 (24A 24N)
10 am 271
2pm 214 (30A)
4pm 117
8pm 287 (24A 24N)
A
DKA k/c/o Type 1 DM with viral pyrexia with theombophlebitis
P
1. IVF NA,RL at 100ml/hr
2. Inj HAI s/c 8am 2pm 8pm
3. Inj NPH s/c 8am 2pm 8pm
4. Temp charting
5. GRBS charting 8am 1pm 8pm 2am
6. BO, PR, RR, SpO2 monitoring
SOAP NOTES DAY 8
http://mahithguduri63.blogspot.com/2021/10/dka.html
AMC Patient
S
Pt is C/C/C
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 120/70 mmHg
PR 87 bpm
RR 16 cpm
SpO2 98 at room air
GRBS
8am 301 (24A 24N)
10 am 250
2pm 256 (26A)
4pm 224
8pm 312 (26A 26N)
10pm 180
A
DKA k/c/o Type 1 DM with viral pyrexia with theombophlebitis
P
1. IVF NA,RL at 100ml/hr
2. Inj HAI s/c 8am 2pm 8pm
3. Inj NPH s/c 8am 2pm 8pm
4. Temp charting
5. GRBS charting 8am 1pm 8pm 2am
6. BO, PR, RR, SpO2 monitoring
