Diabetic ketoacidosis

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A 13 year old girl studying 9th class came with the complaints of shortness of breath, vomitings since today afternoon 

She also complains of rash over abdomen since 3 days

She is a known case of Type 1 diabetes since 3 years

3 years ago she had polyuria for which she was taken to the hospital by her grandmother and was diagnosed with type 1 Diabetes and was kept on insulin 4U of HAI and 4U of NPH in the morning and night and 2U of HAI and 2U of NPH in the afternoon

She was at home during this time as it was lockdown due to COVID

1 year later she was kept on 6U of HAI and 4U of NPH in the morning and night as she cannot take insulin during lunch in school as her school was reopened 

Today’s events

She woke up late, and was in a rush to school so she skipped breakfast. She skipped her morning dose of insulin as she was not having breakfast 

She went to school and at around 11 am she felt dizzy and nauseous and informed that to her teacher, teacher asked her to eat but she didn’t as she was nauseous and she had vomiting with water as content. And slept in the class, and at 12:30pm again she had another episode of vomiting and called her grandfather. He came to school around 1pm and took her home.

Later at home she started developing SOB and in the evening at 5pm she was taken to a local doctor and was put on oxygen and was advised to take her to a higher centre.

Then she came here at 7:30pm

Daily routine 

Wakes up at 6 am in the morning, gets ready to school, takes insulin at 7:15 am 6U HAI and 4U NPH, eats breakfast and goes to school with her grandfather on bike, it takes 10 minutes to get her to school, she eats lunch at 12:30 pm, comes home at 5 pm and eats snacks and go to tution at 5pm. She comes back home at 8 pm and take insulin at 8:15 pm 6U HAI and 4U NPH and eats dinner and does her remaining homework and sleeps at 10 pm

Past history 

No history of similar complaints in the past

H/o trauma (fell from bike while going to school)to Right upper arm, fracture of right humerus and was treated conservatively with cast 1 year ago

Family history 

Her father is a known case of Type 1 Diabetes, diagnosed at the age of 12years

He developed chronic kidney disease 7 years ago and was on dialysis and had died 2 years later

General examination 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema 

Vitals 

PR 158

RR 54

BP 110/60

TEMP Afebrile 

GRBS HIGH

Investigations 

RBS 624 mg/dl

Urine for ketone bodies positive 

Hb: 13.1gm/dl

TLC: 29500 cells/cumm

RBC: 4millions/cumm

PLATELETS: 3.83 lakhs /cumm

Blood urea: 35 mg/dl

Serum creatinine: 0.9 mg/dl

Serum Na+:138mEq/L

Serum K+:4mEq/L

Serum Chloride:99 mEq/L

LFT:

Total bilirubin: 6.47

Direct bilirubin: 0.56

SGOT:42

SGPT:44

ALP: 406

Total proteins: 6.6

Albumin: 4

A/G Ratio: 1.6

CUE

Albumin: +

Sugars: ++++

Epithelial cells: 2-3/ HPF

Pus cells: 2-3/HPF

Diagnosis 

Diabetic ketoacidosis k/c/o Type 1 Diabetes mellitus