65 yr old female with vomitings,decreased urine output
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CASE DISCUSSION:
A 65 yr old female who is a vegetable vendor was apparently a symptomatic 4 months back then she started developing oedema of left leg Which extended till knee associated with pain,redness,blisters seen so patient went to local RMP for symptomatic cure,took tablets ( records not available?) pain got relieved,but the oedema was progressing.So patient went to local hospital where I.V antibiotics, fluids are given. Initially oedema was subsided but later on again it was progressively increasing.The patient went to another Hospital where it was diagnosed Diabetic foot ,? Left leg cellulitis where a knick was given in the left foot and pus was drained about 450-500 ml,the patient was referred to another hospital in view of uncontrolled DM where they tried to manage conservatively,but did not got subsided with treatment and started developing vomitings and decreased urine output since 4 days with serum creatinine- 3.8 mg/dl referred to KIMS for further treatment.
Past history : The patient k/c/oDM since 20 yrs
On metformin (500mg)
K/c/oHTN since 15 yrs on Temisartan
(40mg)
h/o Angina ? 10 yrs back
h/o TB 10 yrs back and ATT was used
For 6 months
h/o right side CVA 6 years back
Personal history: Diet : mixed
Appetite : reduced since admission in
Our hospital
Sleep : adequate
Bowel and bladder:Decreased urine
Output
No addictions
Family history:No similar events of
Complaints were seen in the family
Drug history: Not allergic to any known drugs
GENERAL PHYSICAL EXAMINATION
Patient is conscious, coherent , cooperative moderately built and nourished
No signs of pallor, icterus, cyanosis , clubbing, koilonychia , pedal oedema , skin discolouration on dorsal aspect of left foot and ulcer is seen on medial aspect of foot
Vitals : Afebrile
BP : 150/90 mmhg
Pulse: 94 bpm
RR: 18 cpm
SPo2: 98% RA
SYSTEMIC EXAMINATION
CNS : Higher mental functions normal
Cranial nerves : intact
Sensory system :intact
Rt. Lt
Motor system : Bulk: N. N
Power:N. N
Tone: N. N
Reflexes:Present. Present
No cerebellar signs
CVS: s1, s2 heard , No murmurs
RS : B/L AE present, Normal vesicular breath
Sounds
Per abdomen: soft, no local rise of
Temperature, No tenderness,
No organomegaly
PROVISIONAL DIAGNOSIS: Diabetic ketoacidosis
DAY 1:
ABG: at 6pm
CUE:
Inj HAI infusion started 6ml/hr and changed to 5ml/hr at 11pm
IV fluids-0.9%NS -continuous infusion 150 ml/
5Dextrose -150ml/hr
GRBS monitoring hourly
DAY 2:
Inj HAI infusion @3ml/hr
Iv fluids are given @ 150 ml/hr
Inj.pan 40mg Iv.stat
Inj zofer 4mg Iv OD
GRBS monitoring hourly
RBS at 12 am
serum electrolytes at 12 am
ABG at 12am
Urine for ketones negative at 12 am
ABG at 6am
PH:. 7.34
Pco2:.25.7
Po2:.120
Hco3:. 13.5
St.Hco3:16.0
Serum electrolytes at 6am
Sodium:134
Potassium:3.6
Chloride:105
Serum creatinine
DAY 3
Inj HAI @1.5ml/hr
At 1pm HAI 5U was given SC and is continued 2 hourly
Iv fluids are given,At 3 pm insulin infusion was stopped.
Serum electrolytes:
GRBS charting:
ABG :
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