50/F with diabetic keto acidosis

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A 50year old female patient who resides at presented to casualty with complaints of  pain abdomen 2 days back, regurgitation of food .

Patient was apparently asymptomatic 15 years back then she had a episode of giddiness,was  taken to hospital and diagnosed with Hypertension  and on regular medication MET-XL25 mg.

Till 6 years back she is doing well developed Bilateral knee joint pain for which  she was advised to take anlgesics .

She started to take antacid medication since 4 years 

1 month back patient developed facial puffiness,pedal edema was taken to nearby hospital and  was told she is having Fatty liver managed conservatively from then she used to develop pedal edema on &off .

Patient complaining of  loss of appetite, regurgitation of food, difficulty in swallowing

5 days back 

1 episode of vomiting bilious ,non projectile ,food as content  

3 episodes of loose stools non sticky,foul smelling, yellow coloured, small quantity,not associated with blood  

Abdominal pain squeezing type non radiating , continuous in nature,with no aggravating and relieving factors 

Pt presented to casualty on 3/6/23 evening 

On checking her GRBS it was found to be HIGH.

URINE for ketone bodies found to be positive.

Past History:

Not a k/c/o Tb, epilepsy,cad,CVD,Asthma, thyroid disorders.

Family History 

Not significant

Personal History:

Pt is having loss of appetite, vowel movements increased ,micturition- 7-8 times /day ,sleep - inadequate,No addictions.

Daily routine:

Patient used to be a maid 6 years back and stopped working due to bilateral knee joint pain and used to stay at home

Patient wakes up at 6:30 am ,does her daily activities and drinks Java at around 7:30 , breakfast by 8 am ,watches Tv will have her lunch by 2 pm ,takes Tea by 6 pm and dinner by 9 pm and sleeps by 10 pm.

General Examination:

Pt is conscious, coherent,cooperative 

Pallor present

no icterus,cyanosis, clubbing,generalised lymphadenopathy,edema.

Clinical images:

picture showing pale palpebral conjunctiva

VITALS:

Bp-130/80 mm Hg

Pr-97 bpm

Rr-25 cpm

Temperature:Afebrile

Spo2: 98%@RA

GRBS- HIGH

SYSTEMIC EXAMINATION:

P/A:

Inspection:

Abdomen is distended

Infraumblical vertical scar present

No sinuses,,pulsations, peristalsis.

Umblicus is central and inverted

All quadrants of Abdomen move equally  with respiration.

Palpation:

No local rise of temperature

Tenderness present in the Right ,Left Hypochondrium and Epigastrium.

No fluid thrill 

Liver is palpable

Spleen not palpable

Percussion:

Resonant note is heard on percussion

 shifting dullness negative

Auscultation:

Bowel sounds are heard.

Cvs:

S1,S2 heard No murmurs

CNS:

No focal neurological deficit 

Rs:

Bae+

Normal vesicular breath sounds heard.

Investigations:

URINE for Ketone bodies: Positive 

Serum osmolaity:

Glycated Hemoglobin 

Abg and serum electrolyte values

Hemogram 

Liver function test

Blood Culture Report:

Urine Culture Report:

Usg Abdomen:

No sonological abnormalities detected

Chest X ray:

Ecg:

2d echo

Provisional Diagnosis:

?Diabetic ketoacidosis ?Starvation ketoacidosis with Acute Gastroenteritis with Denovo DM2.

Treatment:

1.IVFluids NS @100ml/hr

2.Inj.HAI  infusion 1ml(40U)in 39 ml NS@4ml/hr increase or decrease according to GRBS

3.IV 5Dextrose@50ml/hrincrease or decrease according to GRBS

4.Strict I/O CHARTING

5.monitor Vitals Hourly