A 65 year old male with DKA with community and acquired pneumonia and pre renal AKI

-

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references
 

A 65 year old male was brought to casualty with


CHIEF COMPLAINTS


Fever since 4 days

Breathlessness since 1 day

HISTORY OF PRESENTING ILLNESS 


Patient was apparently asymptomatic 10 days back when he developed cold and cough with expectoration which is greenish and mucoid. Now the expectoration has decreased. 

Then developed fever 4 days back which is high grade, continuous and not associated with chills and rigor.

Complaints of decreased appetite since 3days

And shortness of breath since 1 day     - grade - II now increased to grade - IV since last night.

H/o nausea but no vomiting 

No H/o decreased urine out put, pedal edema, loose stools


DAILY ROUTINE

He is a shopkeeper by occupation according to the attender his daily routine is as follows 

6 am: takes a cup of tea with sugar 

6:30 am: he opens his shop

If he takes a breakfast it's b/w 7-7:30 am

9 am: takes a cup of tea with sugar

11 am: bathes and goes to his shop again

12:30 pm: he eats his lunch 

4:30-5:30pm: he again consumes rice

6:00 pm: takes a cup of tea w sugar 

7:30 pm: takes his dinner which consist of rice 

9 pm: he sleeps


PAST HISTORY


N/K/C/O DM, HTN, TB, Epilepsy, CVA, CAD

Complaints of pain in bilateral knee joints for which he takes NSAIDS when pain increases.

H/o Surgery for right tibial fracture 5 years back


PERSONAL HISTORY


Diet : Vegetarian

Appetite : Normal before 3 days


Sleep: adequate

Bowel and bladder : Normal

Addictions : used to smoke but stopped 5 years back


FAMILY HISTORY


Not significant


GENERAL EXAMINATION


Patient conscious and coherent not co-operative






VITALS

 
Pulse : 98bpm

RR :  21 cpm 

BP :  90/60 mm Hg

Temp. :  99°F

SpO2 : 96%
 



SYSTEMIC EXAMINATION


CVS : S1, S2 hear, no thrills and murmurs 

Rs : position of trachea - central

BAE +,   NVBS +

decreased breath sounds in infra axillary and mammary area

Dysnea, wheeze, rales and ronchi - absent

Abdomen: scaphoid shaped, soft and diffuse tenderness 




CNS 

Drowsy, arousable 

Slurred speech 

No neck stiffness

Cranial nerves

Tone : Normal in both the limbs
 
Power : 4/5 in both the limbs


Reflexes :            Right              Left

      Biceps             ++                   ++

      Triceps           ++                   ++

      Supinator       +                       +

      Knee               ++                    ++

      Ankle             ++                    ++

      Plantar       Flexor            Flexor


Cerebellar examination : normal


PROVISION DIAGNOSIS 


? Diabetic ketoacidosis secondary to respiratory disease


INVESTIGATIONS















































Glucose monitoring 




FINAL DIAGNOSIS


Diabetic ketoacidosis with community acquired pneumonia with pre renal AKI.


TREATMENT 



2/12/2023

1) NBM until further orders

2) IV Fluids NS @ 100ml/hr

3) Inj. PIPTAZ 2.5gm IV/TID

4) Inj. LINEZOLID 600mg IV/BD

5) Tab. AZITHROMYCIN 500mg OD

6) Tab. FLUCONAZOLE 150 mg OD

7) Inj. HOMAN ACTRAPID INSULIN infusion @ 6units/hr

8) Inj. PCM 18g IV/SOS ( if temp. >= 101°F)

9) Inj. LASIX 20mg IV/BD ( if SPB >= 110)

10) IV Fluids - FRUSIDEX @ 50ml/hr

11) Tab. ATORUAS 40mg OD

12) Tab. CLOPITAB - A75/75 OD

13) Inj. PAN 40mg IV/OD

14) GRBS moniter hourly
 
15) Moniter BP, PR, RR, SPO2 Hourly


8:40 PM

1) Stop insulin infusion

2) Inj. HAI 6U in 500ml DNS over 5hrs

3) Inj. KCL 20mEq in 500 NS over 5hrs

Followed by 

4) Inj. KCL 20mEq in 500 NS over 5hrs

5) GRBS moniter hourly



3/12/2023

1) Inj. PIPTAZ 2.25gm IV/TID

2) Inj. LINEZOLID 600mg IV/BD

3) Tab. AZITHROMYCIN 500mg OD

4) Tab. FLUCONAZOLE 150 mg OD

5) Inj. PAN 40mg IV/OD

6) Inj. PCM 1g IV/SOS ( if temp. >= 101°F)

7) Inj. LASIX 20mg IV/BD ( if SPB >= 110)

8) Inj. HOMAN ACTRAPID INSULIN infusion  S/L TID according to GRBS

9) Tab. ATORUAS 40mg OD

10) Tab. CLOPITAB - A75/75 OD

11) GRBS moniter 2 hourly

12) Moniter BP, PR, RR, SPO2  2 Hourly

13) Nebulization with IPRAVENT 8th hourly and BUDECORT 12th hourly

14) Inj. KCL 20mEq in 500 NS over 5hrs

15) Tab. FENOFIBRATE 160mg OD

16) Tab. METOPROLOL 25mg OD

17) IV fluid DNS with 6u HAI + 20mEq KCl at 100ml/hr









Comments

Post a Comment

Popular posts from this blog

Pre final OSCE and Learning points

-
Image
  The case allotted to me one day before the exam is presented in the following log which can be found here https://126singareddymanasa.blogspot.com/2023/12/a-65-year-old-male-with-dka-with.html OSCE 1) Can diabetes cause Fatty liver, if yes how?      Yes, Diabetes can cause fatty liver.  Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in type 2 diabetes mellitus.  The pathogenesis of NAFLD is not yet fully understood, but insulin resistance appears to be a critical contributing factor with obesity as the most common cause of the insulin resistant. As body fat stores expand with  excess calories and progressive obesity, alterations in lipid metabolism along with inflammation in adipose tissue and ectopic sites of fat deposition lead to insulin resistance. Insulin resistance leads to increased its accumulation in body. This excess insulin increases lipolysis and increases the production of free fatty acids. The surplus amount of fatty acids cause an excess production of tr
Read more

General medicine - Formative assessment

-
Online bimonthly assignment Singareddy Manasa 3rd Semester Roll no. - 126          I have been given the following cases to solve in an attmept 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 diagnosis and treatment plans and to give review on the answer of the respective cases . This is the link of the questions asked regarding the cases   http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 Question 1 : 1) PULMONOLOGY Case :  https://anuragreddy72.blogspot.com/2021/05/online-blended-bimonthly-assignment.html It is a case of  A 55 year old female patient, with the chief complaints of shortness of breath, pedal edema and facial puffiness. After going through the history of patient, doing all required examinations and investigations, the provisional diagnosis is given as Acute exacerbation of COPD associat
Read more