1801006049 SHORT CASE

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A 49year old man autodriver by occupation from AP Lingotam came with complaints of vomitings from 2days 

History of presenting illness:

He was apparently asymptomatic 10years ago then went to a hospital for fever and generalised weakness and was diagnosed with diabetes and was started on oral hypoglycaemic agents(Metformin). 

6years ago, he had history of vomitings and found to have low potassium levels for which he was accordingly managed.

2 days ago around 3am he started to have vomitings, 8-9 episodes non bilious, non projectile, with food as content. He went to a local hospital and found his sugar levels were high  and was referred to our hospital.

Past history:

H/o Diabetes mellitus since 10 years and is on regular medication (Tab.Metformin 500mg)

No H/o CAD, Tuberculosis, epilepsy, asthma

Family history: 

No member of family has similar complaints 

Personal history:

Appetite: Normal

Diet: Mixed

Bowel and bladder movements:regular

Sleep: adequate 

Addictions: He consumes alcohol 90ml occasional and smokes beedi 1pack daily

Daily routine: 

He waked up at 6am in the morning and goes to work (auto driving) at around 8am. He takes his breakfast at 10am and does his work. He usually have his lunch at 1pm and continues with his work and then comes home at around 7pm eats dinner at 9pm and sleeps at 10pm.

General Examination:

Patient is conscious, coherent and cooperative

He is moderately built and nourished.

No Pallor, Icterus, Cyanosis, Clubbing, Generalised lymphadenopathy, B/l pedal edema.

Vitals:

Temperature: Afebrile

Pulse rate: 100bpm

Blood pressure:160/90mmHg

Respiratory rate:18cpm

GRBS: 416mg/dl on day of admission

Systemic examination:

Respiratory system: 

Inspection- elliptical shape

Bilaterally symmetrical movements on respiration 

B/l air entry present, normal vesicular breath sounds heard 

Cardiovascular system: 

Apex beat left 5th intercostal space

S1, S2 heart sounds heard, no murmurs heard

Central nervous system: 

He is conscious

Speech: normal 

Tone:

      upper limbs:normal 

      Lower limbs:normal 

Reflexes:

Superficial reflexes are present 

Deep tendon reflexes:

Right side:                            Left side:

Biceps:  2                                  2

Triceps:  2                                 2

Supinator:2                               2

Knee:     2                                  2

Ankle:    1                                 1                           

Per abdomen: flat, no distension 

Soft, non tender 

Liver: not enlarged 

Spleen: non palpable

Provisional diagnosis:

Diabetic ketoacidosis 

Investigations:

Hb: 12.3gm/dl

RBC:6.05 mil/cumm

TLC:11,300 cell/cumm

Platelet count:3.24lakh

ABG:

pH 7.14

Pco2 46mmHg

Po2  125mmHg

HCO3 15mmol/L

Urine examination:

Sugars: ++++

Ketones:+

Treatment:

IV fluids NS@125ml/hr

Inj.NPH SC BD

Inj.HAI SC TID

Inj.OPTINEURON 1amp in 100ml NS IV OD

Inj.ZOFER 4mg IV

Inj.NEOMOL 1gm IV

Tab.ECOSPRIN 150mg OD

Tab.CLOPITAB 75mg OD

Tab.ATORVASTATIN 40mg OD

Tab.TELMA 40mg OD