A 49 YEAR OLD MALE WITH DIABETIC KETOSIS SECONDARY TO ?ACUTE GASTROENTERITIS

 A 49 YEAR OLD MALE WITH DIABETIC KETOSIS SECONDARY TO ?ACUTE GASTROENTERITIS 

This is an online E log book to discuss our patient's de-identified health data shared after taking her guardian's signed informed consent.

Name : N MANOHARA PRASAD

Roll no. - 14

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 also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.

I've 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 a diagnosis and treatment plan.

A 49 Year old male, autodriver by occupation , came to casualty on 24th June 2023 with chief  complaints of-

CHIEF COMPLAINTS:

Giddiness since 5 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 days ago then he developed Giddiness on and off, insidious in onset, gradually progressive

C/o Vomitings 4-5 episodes, watery, non-projectile, bilious with food particles as content. Not Blood tinged. Relieved with medications.

C/o Loose stools: 4-5 episodes, watery, non blood stained, non-mucoid, non- foul smelling.

C/o Pain in Right side of body along with weakness of Right lower limb, 5 days back, now relieved

C/o Facial puffiness since 5 days, LBA+ since 1 day

No C/o Fever, pain abdomen, decreased urinary output, pedal edema.


DAILY ROUTINE

The patient is a Farmer and Autodriver

  • 4AM: Wakes up and Freshens. Goes to look after his farms and comes back at 7AM
  • 8AM: Drinks Tea
  • 9AM: He eats Rice( Daily one cup) with soft drinks (Consumes soft drinks throughout the day whenever he is thirsty)
  • 10AM- 1PM: Goes for driving Auto
  • 1PM: Eats Lunch- Rice with dal 
  • 2PM: Takes an afternoon nap and wakes up at 4PM
  • 4PM: Goes for driving Auto
  • 6:30: Tea and soft drink
  • 8PM: Dinner
  • 10PM: The patient goes to bed by 10PM

PAST HISTORY :

Patient visited local hospital 1 month back with C/o headache, sweating, giddiness and was diagnosed as hypertensive and put on medications.

Patient is a known case of  DM II since 13 years and is on medication. Now using GLIMI-M4 Forte PO/OD(morning) and GLIMI-M3 Forte PO/OD(Night)

K/C/O HTN since 1 week

The patient was operated for haemorrhoids 20 years back

 Not a known case of CAD, Bronchial asthma, Epilepsy, TB.


PERSONAL HISTORY

DIET - Mixed

APPETITE- Decreased since 5 days

SLEEP - Adequate

BOWEL AND BLADDER- Regular

ADDICTIONS - Binge alcoholic since 13 years.Stopped consumption 6 years back- habituated to soft drinks

Chewing tobacco since 20 years.

No known allergies

FAMILY HISTORY

No H/o DM in the family

MARITAL HISTORY:

Married life: 20 years

He has 5 daughters and 1 son.

4 daughters are married and 1 daughter has left home and married against her parents will.

Patient couldn’t take it and was completely depressed and worried about his daughter. He started taking more alcohol since the incident.

GENERAL EXAMINATION

Patient was examined in a well lit room after taking informed consent.

He is conscious, coherent and cooperative; moderately built and well nourished.

No icterus, clubbing, cyanosis, lymphadenopathy, edema.


VITALS on 24/06/2023

  1. BLOOD PRESSURE: 170/100 mmHg
  2. PULSE PRESSURE: 60 Bpm
  3. RESPIRATORY RATE: 14cpm
  4. TEMPERATURE: Aferbile
  5. SpO2: 98% on Room air
  6. GRBS: 428mg/dl 




SYSTEMIC EXAMINATION


1. RESPIRATORY SYSTEM : B/L Air entry Present, Normal vesicular breath sound+


2. CARDIOVASCULAR SYSTEM: S1, S2 heard, no murmurs.

3. ABDOMINAL EXAMINATION : Soft, Non- Tender

4. CNS - No Focal neurological deficits













INVESTIGATIONS 

                                                                            24/06/2023

 RANDOM BLOOD SUGAR 



HEMOGRAM


 

 BLOOD UREA 



 SERUM CREATININE



 SERUM ELECTROLYTES



 COMPLETE URINE EXAMINATION 




URINE FOR KETONE BODIES - 




 



 ABG Analysis



  Seronegative for HIV, HEPATITIS B and C


 USG- Grade I Fatty Liver


  ECG:



2D ECHO



 X-RAY:



25/06/2023


SERUM ELECTROLYTES
12am:

SERUM ELECTROLYTES
6am:







11am:


GLYCATED HEMOGLOBIN



FASTING BLOOD SUGAR


PLBS



HEMOGRAM



LIPID PROFILE

ABG:

26/06/2023
6am

URINE FOR KETONE BODIES:

SERUM ELECTROLYTES 
6pm


27/6/23
HEMOGRAM:


PROVISIONAL DIAGNOSIS

Diabetic Ketosis secondary to ? Acute Gastroenteritis

TREATMENT

  1. Intravenous fluids normal saline @100ml/hr
  2. Injection Human actrapid insulin I.V infusion (1ml +39ml NS) @6ml/hr
  3. Inj. PAN 40mg IV/OD 
  4. Inj. BUSCOPAN IM/ SOS
  5. Tab. TELMA 40mg PO/ OD
  6. Monitor GRBS Hourly
  7. Strict input output charting

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