57 year old male

CASE:

A 57 year old male patient who is a resident of nalgonda and farmer by occupation (lemon field)came to the casualty with altered sensorium since 1 day and Generalised weakness with uncontrolled sugars since 2 days



History of presenting illness:

Patient was apparently asymptomatic 1 year back . In Feb 2022 he started to talk irrelevantly and unable to recognize his family members so they went to a local Rmp who informed the patient attenders that patient is having high sugars and got admitted here to kamineni and diagnosed him with ?DKA HHS. He got few high bp recordings at that time. He also got diagnosed with ckd and having chronic pancreatitis. He had 3 days of hospital stay and and was on HAI (10U(initially 8U)-----X-----12U). Since then he was coming to regular check up every 3 months. 

He was alright since then. But the patient thought his sugars were in control so he stopped taking insulin since 2 days ( last dose was Monday morning 8am). on 25-7-2023 he again started to talk irrelevantly (altered sensorium)and Generalised weakness. Low grade fever which got subsided with medication (DOLO 650mg).

On 26th morning at 11am went to rmp and said to have high sugars and got admitted here in our hospital.

H/o weight loss since 1 year.

H/o headache since 2 days.

No h/o vomitings , abdominal pain, sob, palpitations.

Daily routine:

His occupation is agricultural worker (lemon field)

Before 1 year(before he got diagnosedwith diabetes)- 

The patient used to eat rice 3 times a day and goes to work at 9 am and comes back to home at 5 am and watches TV and sleeps at 8 pm after having food.

After he got diagnosed with DM 2 -

He changed his dietary habits. He eats Gatka(made of jonna)(HAI 10U) as breakfast and drinks milk. And goes to work at 9am and at 1pm he has rice for lunch and at 5 pm he gets back from fields and drinks milk and watches TV and has royi at 7pm and takes his night dose of insulin (HAI 12 U)and goes to sleep at 8 pm.

Daily routine:

His occupation is agricultural worker (lemon field)

Before 1 year(before he got diagnosedwith diabetes)- 

The patient used to eat rice 3 times a day and goes to work at 9 am and comes back to home at 5 am and watches TV and sleeps at 8 pm after having food.

After he got diagnosed with DM 2 -

He changed his dietary habits. He eats Gatka(made of jonna)(HAI 10U) as breakfast and drinks milk. And goes to work at 9am and at 1pm he has rice for lunch and at 5 pm he gets back from fields and drinks milk and watches TV and has royi at 7pm and takes his night dose of insulin (HAI 12 U)and goes to sleep at 8 pm.

Past history:

IN 2021 He had cough with sputum(muvoid) fir 2 yo 3 days and got tested positive for TB (compliant with 6 months ATT therapy). And gotbtested negative for tb after 6 konths of therapy.

K/c/o diabetes since 1 year on HAI (10U-----X-----12U)

Not a known case of Hypertension, asthma epilepsy, CAD,CVA

Personal history:

Diet-mixed 

Appetite-normal 

Sleep-adequate 

Bowel and bladder movements-regular 

Addictions- alcohol intake and toddy deinker since 30 years daily since 1 year occasional drinker . Beedi smoker (10-15/day) and cigarette smoking occassionally stopped smoking since 1 year.



Family history:

Not significant 

General examination:

Patient is non coherant,conscious, cooperative 

Moderately nourished and moderately built .

No pallor,Icterus, cyanosis, clubbing lymphadenopathy, edema



Vitals:

Temp:99.1F

BP- 120/70 mmhg

PR- 88 bpm 

RR-20 cpm

Grbs-650 mg/dl

Systemic examination:

CNS: 

Patient is not coherant 

Speech -normal.

Cranial nerve examination-normal 

Tone-normal.

Power-5/5 in all limbs.

Reflexes: Right left 

      Biceps ++ ++

      Triceps ++ ++

      Supinator ++ ++

      Knee ++ ++

      Ankle + +

      Plantar flexor flexor 

Cerebellar examination-normal.



CVS-s1,s2 heard and no murmurs.

RS- BAE +, NVBS

P/A- Soft and nontender.


Provisional diagnosis:

Diabetic ketoacidosis secondary to non compliance to insulin.



Investigations:

On 26-07-2023
USG abdomen


ECG

X ray chest


HbA1c -8 gm%


Treatment:
1.NBM till further orders.
2. Iv Fluids NS @75 ml/hr
3. Inj. CEFTRIAXONE 1gm iv /bd
4. Inj. HAI 6 U IV /STAT FOLLOWED BY INJ. HAI 1ML +39ML NS INFUSION AT 6 ml /hr(increse or decrease according to grbs).

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