A 24 years old male with DKA

I have 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 diagnosis with a treatment plan.

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

A 24 year old, sand contractor by occupation, came with complaints of 

• Generalized weakness since 10days
• Loss of appetite and loss of weight since 10 days

History of presenting illness 

Patient was apparently asymptomatic 10 days back and then developed generalized weakness, loss of appetite and weight loss (approx 5 kgs) for which he came to the hospital and got diagnosed with Diabetes, one day back. 

No h/o fever, abdominal pain, vomittings, diarrhoea, chest pain or palpitations. 

 Patient also complained of increased frequency of micturition since 9days, he had to wake 4-5 times at night to urinate and passed urine 3 times in the day. Gives history of increased thirst as well. 

Patient gives history of one episode of Giddiness 2 weeks and went to local RMP, where they recorded a BP of 180/100 mm Hg, so they gave him injections and tablets(unknown). 

No previous hospital admissions. 

Past history 

Patient’s mother reports that till the age of 5, patient had Shortness of breath and weakness and when they consulted a Doctor, they were told he has a hole in his heart. 

He didn’t receive any treatment for it neither did he undergo any surgery. 

She says it improved with age. 

No history of thyroid disorders, epilepsy, TB, CAD. 

Family history: 

Patient’s father got diagnosed with Diabetes Mellitus and Hypertension 3 years back and is using medication for it. 

Personal history:

Diet-mixed

Sleep-adequate 

Appetite-decreased since 10 days

Bowel-regular

Bladder-increase in frequency

Addictions-consumes alcohol since 12 years 2 to 3 times a week and consumes toddy daily.

General examination 

Patient is conscious, coherent and cooperative. 

No pallor

No icterus

No cyanosis

No clubbing

No koilonychia

No lymphadenopathy 

No bilateral pedal edema.

Redness of eyes present.

Vitals: Temp: 98.6 °F

PR: 75 bpm

BP: 130/80 mm Hg

SpO2: 98%

GRBS: 109mg/dl 

Systemic examination

CVS examination: 

S1 S2 present 

No murmurs, thrills. 

Respiratory System examination: 

Bilateral Airway Entry present. 

No wheeze, dyspnoea or adventitious sounds. 

CNS: 

HMF: intact. Conscious. 

 

Abdomen examination:

Palpable,non tender.

ECG:

 

Chest X Ray: 

Provisional diagnosis:

Diabetic KetoAcidosis with de novo detected  ?Type I Diabetes Mellitus 

Treatment:

1. Allowing soft diet 

2. Inj. HAI 10U TID

10U——10U——10U

3. Inj. NPH 15U BD

15U——X——15U

4. GRBS before food and 2hours after food