20year old with denovo diabetes with diabetic keto acidosis

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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 come up with diagnosis and treatment plan.This is an a 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.

A 20 year old female was bought to the casuality with 

- c/o fever since one day

- c/o altered sensorium since morning 

History of presenting illness - 

Patient was apparently asymptotic one day back then developed fever,high grade , associated with chills and rigor , no diurnal variation , relieved with medication 

Altered sensorium since morning 

No c/o burning micturation ,vomitings, loose stools , chest pain,palpitations, Orthopnea 

H/o polyphagia,polydipsia 

Past history- 

Not a k/c/o DM,HTN,THYROID DISORDER,CVA,EPILEPSY 

Personal history:

Diet:Mixed 

Appetite:Decreased 

Sleep-adequate

Bowel movements-regular

Bladder movements- normal urinary output

Addictions-none 

Family history: Not significant 

General examination:

Patient is conscious,coherent,cooperative and well oriented with time,place,person

Poorly nourished and thin built 

No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy 

Vitals:

Temperature: 98.4 degree Fahrenheit

BP-150/100mmHg

PR-113bpm

RR-213cpm

Grbs- 540mg/dl

Spo2 -97@RA

SYSTEMIC EXAMINATION:

A.CARDIOVASCULAR SYSTEM

Inspection: 
•  Chest is bilaterally symmetrical.
•. Trachea is central 
•. Movements are equal bilaterally
•.  JVP:Normal  
• NO Visible epigastric pulsations 
• No scars or sinuses
•Apical impulse seen in left 6th 
intercostal space lateral to mid 
clavicular line


Palpation:
•All inspectory findings are confirmed: 
Trachea is central, movements equal bilaterally. 
•Antero-posterior diameter of chest :Transverse  
diameter of chest increased 
•Apex beat felt in left 6th intercostal space lateral 
to midclavicular line

 
 Auscultation: 
•S1 S2 heard
•No murmurs


RESPIRATORY SYSTEM:
Inspection: 
•Chest is bilaterally symmetrical.
•Trachea is central 
•Movements are equal bilaterally
•No scars or sinuses
•Apical impulse seen in left 6th ICS lateral to MCL

Palpation:

•All inspectory findings are 

confirmed: 

Trachea is central, movements 

equal 

bilaterally. 

•Antero-posterior diameter of 

chest is more than

Transverse diameter of chest

•Apex beat felt in 6th intercostal 

space lateral to midclavicular line

Percussion: 

•Resonant note heard in all  

areas bilaterally

 

Auscultation: 

•Bilateral air entry present – 

Normal vesicular breath sounds 

•Vocal resonance normal 

                                    

PER ABDOMEN:

•Scaphoid

•No  engorged 

veins/scars/sinuses

•Soft , non tender

•No organomegaly

•Tympanic node heard all over 

the abdomen

•Bowel sounds present

CNS:

•HMF - Intact

•Speech – Normal

•No Signs of Meningeal 

irritation

•Motor and sensory system – 

Normal

•Reflexes – Normal

•Cranial Nerves – Intact

•Gait – Normal

•Cerebellum – Normal 

•GCS Score – 15/15

Provisional diagnosis: 

Diabetic ketoacidosis

Investigation:

Serum electrolytes 

Na -145mEq

K- 3.5 mEq

Ca 1.25

Abg -

Ph- 7.44

Pco2-24.4

Po2-97.6

Hco3 - 16.6

Treatment 

Day 1

Ns @150ml/hr

Inj HAI 1ml in 39ml ns 

@6ml/hr

Inj sodium bicarbonate 10ml

Inj pan

Inj zofer

Inj monocef