22 year old male with shortness of breath with uncontrolled type 1 DM

Kausalya Varma, MBBS 8th semester

Roll no: 59

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22 YEAR OLD MALE WITH SHORTNESS OF BREATH AND UNCONTROLLED TYPE 1 DM

CHIEF COMPLAINTS:

A 22 year old male came to the casualty on 16/10/21 at 5:14pm with a history of fever since the previous day and shortness of breath since that morning.

HISTORY OF PRESENTING ILLNESS:

He was apparently asymptomatic one day ago after which he presented with fever since the past 1 day.

He has a history of cough, that was dry in nature and he had a cold for the past day.

He also complained of chills at night.

He had been complaining of shortness of breath since 2:00pm.

Patient was apparently asymptomatic 12 years ago when he presented to the casualty with shortness of breath and was diagnosed to have type 1 diabetes mellitus. He has been on Inj Insulin 20 units BD for the past 12 years. For the past 2 years, he has only been takin Inj Insulin 20 units once a day, in the morning.

He now presents with shortness of breath for the past 4 hours and a GRBS of 509 mg/dl.

PAST HISTORY:

Medical history-

The patient is a known case of type 1 diabetes mellitus for the past 12 years.

He has been on Inj Insulin 20 units BD for the past 12 years and has been taking it once a day only in the morning for the past 2 years.

Has been admitted in the hospital 6 times, once a year over successive years after being diagnosed with similar complaints like difficulty in breathing, abdominal pain and vomitings.

The episodes usually occur on days which he has skipped meals but taken the insulin and not associated with any fever, infections or other external or internal stress.

Not a known case of HTN, TB, Epilepsy, CAD, CVD or bronchial asthma.

Surgical history- No relevant surgical history

PERSONAL HISTORY:

Diet- Mixed

Appetite- Normal

Sleep- Adequate

Bowel and bladder- Regular

Addictions- No known addictions

He does not take part in any physical activities or sports and leads a sedentary lifestyle.

Experiences difficulty in breathing only on physical exertion.

GENERAL EXAMINATION:

The patient was conscious, coherant, and co-operative and well oriented to time, place and person.

Pallor- Absent

Icterus- Absent

Clubbing- Absent

Cyanosis- Absent

Lymphedenopathy- Absent

Edema- Absent

VITALS-

Temperature- Afebrile

BP- 110/80 mmHg

Pulse- 98 bpm

Respiratory Rate- 32 cpm

Oxygen saturation- 99% on room air

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM- Bilateral airway entry, Normal vesicular breath sounds heard

CVS- S1 and S2 heard, no added murmurs

PER ABDOMEN- Soft and tender, No organomegaly

CNS- NAD

Chest X-ray on day of admission (16/10/21)

PROVISIONAL DIAGNOSIS:

Diabetic ketoacidosis due to inadequate insulin dose in type 1 diabetes mellitus.

TREATMENT:

Nil by mouth

IVF- Normal saline/Ringer lactate 150 ml/hr

Inj HAI infusion at 40 ml/hr (39ml + 1ml HAI)

Inj PAN 40mg IV OD before breakfast

Tab Dolo 650mg po sos

GRBS- charting per hourly

Temp/BP/PR/spO2 charting hourly

NOTES-

Day 1-

Subjectivity- Patient complains of headache and vomiting

Objectively-

Patient is conscious, coherent and cooperative

BP- 110/70 mmHg

PR- 107 bpm

Temp- 97.8 F

GRBS-

CVS- S1, S2 sounds heard

Respiratory system- Bilateral airway entry, non vesicular breath sounds heard

Per abdomen- soft and non tender

Assessment- Diabetic Ketoacidosis

1) IVF- NS/RL at 100 ml/hr

2) Inj HAI 39 ml INS + 1 ml (HAI at 4 ml/hr)

3) Inj PAN 40 mg IV OD

4) T PCM 650 mg PO TID

5) Syrup Ascorbyl 5 ml PO BD

6) Tab Levocetrizine 10 mg PO HS

7) Inj Optineuron 1 amp in 500 ml NS IV OD

8) Inj Ceftriaxone 1 g IV BD

Chest X-ray (18/10/21)

Day 2-

Subjectively- Patient complains of headache

Objectively-

Patient is conscious, coherent, and cooperative

BP- 110/60 mmHg

PR- 88 bpm

RR- 20 cpm

GRBS- 274 mg/dl

Temp- 97.8 F

CVS- S1, S2 positive

RS- Bilateral air entry, non vesicular breath sounds heard

Per Abdomen- Soft and non tender

Assessment- Diabetic Ketoacidosis

Treatment Plan-

1) IVF- NS/RL at 100 ml/hr

2) Inj NPH- 8am-8pm (according to the GRBS)

3) Inj HAI- 8am- 2pm- 8pm

4) Inj PAN 40 mg IV OD

5) T PCM 650 mg PO TID

6) Syrup Ascoryl 5ml PO BD

7) Tab Levocetrizine 10 mg PO HS

8) Inj Optineuron 1 amp in 500ml NS IV OD

9) Inj Ceftriaxone 1g IV

These are a record of the investigations done day wise for the patient-

16/10/21-

Serum creatinine- 1.0

Blood urea- 35

Na- 13.8

K- 4.5

Cl- 98

LFT-

Total bilirubin- 0.85

Direct bilirubin- 0.18

AST- 10

ALT- 10

ALP- 291

Total proteins- 6.6

Albumin- 3.5

A/G- 1.1

Hemogram-

Hb- 12.6

TLC- 11,200

Neutrophils- 88

Leukocyte- 0.9

PCV- 36.4

RBC- 4.29

PLT- 3.12

Urine sugars +ve

Urine ketone bodies +ve

Urine albumin +2

17/10/21-

Serum electrolytes-

Na- 132

K- 4.4

Cl- 97

18/10/21-

Serum electrolytes-

Na- 139

K- 3.7

Cl- 94

pH- 7.39

pCO2- 26.0

HCO3- 15.6

pO2- 96.0

This is the TPR graphic sheet of the patient day wise recorded since the day of admission.

Day 3-

The patient was shifted to the ward.

Subjectively- No new complaints

Objectively-

BP- 120/80 mm hg

PR- 70 bpm

RR- 22 cpm

GRBS- 114 mg/dl

Temp- 99.8 F

CVS- S1 S2 sounds heard

RS- Bilateral air entry, Non vesicular breath sounds heard

Per Abdomen- soft and non tender

Assesment- Diabetic ketoacidosis

Treatment Plan-

Continue iv fluids

Inj HAI 8am(10U)---1pm(8U)---8pm(6U)

Inj NPH 8pm(10U)--------8pm(6U)

Inj ceftriaxone 1gm IV BD

Inj optineuron OD

Syp benadryl PO BD

The patient has been sent for an ophthalmic referral on 18/10/21 to examine for diabetic retinopathy as he has been diagnosed with type 1 DM for the past 12 years.