A 34 year old male with dka

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-Complaints of shortness of breath since two days on and off increased since morning

-complains of fever since two days

- complains of burning micturition since two days

HOPI:

Patient was apparently a symptomatic five years back then he was diagnosed with diabetes mellitus for which he was started on oral hypoglycaemic drugs later was advised insulin after two years of usage of oral hypoglycaemic agents patient had similar episode 15 days back and got admitted at private hospital and was on unknown medication following missing insulin  for two days 

history of DKA 1 yr ago  admitted in our hospital

Patient complains of SOB since two days ,(progressed to grade 4 today morning)not associated with cough ,cold ,chest pain ,Giddiness

 complains of fever, high-grade not associated with chills since two days associated with burning maturation not associated with vomiting ,loose stools, history of missing insulin dosage and  not eating since two days due to work stress nonavailability of insulin 

Patient is Known case of diabetes since seven years on isophane insulin 25 units

 history of recurrent Dka  15 days back and one year back

N/K/C/O HTN,BA,TB,CVD

GENERAL EXAMINATION 

Patient is Conscious, coherent,co operative well oriented to Time,place,person

No pallor, No icterus, No Cyanosis, No Lymphadenopathy, No Edema

VITALS

Temperature -98F

Pulse rate- 98bpm

Blood pressure-140/90mm hg

Respiratory rate -20cpm

SYSTEMATIC EXAMINATION:

PER ABDOMEN:Soft, non tender

No guarding, No rigidity 

Bowel sounds present 

CARDIOVASCULAR SYSTEM:

S1,S2 heard, NO Murmurs 

RESPIRATORY SYSTEM:

BAE present,NVBS

CENTRAL NERVOUS SYSTEM:

NAD

PROVISIONAL DIAGNOSIS-DKA

INVESTIGATIONS 

Hb-14

Tlc-23000

Rbc-4.82

Blood urea-32mg/dl

TB-1.31

DB-0.56

SGOT-14

SGPT-10

ALp-261

TP-6.6

Alb-4.42

A/G-2.03

S creatinine-1

Na-142

K-4

Cl-103

Urine ketones-positive

Grbs charting

26/5/22

2am-222mg/dl8

8am-324mg/dl - HAI 15U

10am-287mg/dl

12pm-253mg/dl- HAI 15U

2pm-220mg/dl

8pm-100 mg/dl -4 N +8 A

10pm-197mg/dl

27/5/22

2am-166mg/dl

8am-260mg/dl-6NPH+10HAI

Treatment 

1.INJ PAN 40MG IV

2.INJ MONOCEF 1gm IV BD

3.IVFNS 3,RL 1 @150ml/hr continuous

4.INJ HAI S/c 14 U STAT

5.INJ HUMAN ACTRAPID INSULIN INFUSION

(1unit in 39ml NS )@ 6mp/hr

6.START 5% D INFUSION @100ml/hr if GRBS <200mg/hr

7.maintain GRBS 150-200mg/hr

8.INJ NAHCO3 50 meq IV /stat f/b 150meq in 1.NS @ 250ml/hr

9.INJ ONDEM 4mg SOS

10.GRBS MONITORING HOURLY

11.4th HOURLY TEMP CHARTING

12.INJ KCL 1 amp in 100 ml NS over 4-5 hrs