45 F with DKA (resolved) K/c/o DM- II/HTN/ CKD on HD with Diabetic Nephropathy with hypertensive retinopathy with anemia secondary to ? Iron deficiency

MEDICINE CASE DISCUSSION

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CASE SCENARIO:

A 45 yr old female came to casuality in altered sensorium since 3 am today. 

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 20 years back diagnosed as ? DM - I and started on Inj. Mixtard.

In the month of APRIL: 

Patient went to the hospital with complaints of swelling of feet since 1 month and SOB on exertion since 1 month. She also had Increased frequency of micturition at night (Sr. Cr- 3.6 to 4.2, Hb- 8.5)

She was on Inj. Mix 22U - - X - - 10U

MAY: 

c/o decreased appetite, easy fatiguability 

Inj. Mix 15U - - X - - 5U

JUNE: 

(Hb : 7.4) Cr: 5.3 Alb: 3.0

Inj. Mix 12U - - X - - 5U

She was advised AV fistula

JULY: 

fever + chills, swelling over AV fistula associated with pain and tingling sensation (? Cellulitis of left upper limb) 

Received 2 units of packed cells

Hb: 4.7 

Cr: 4.8

AUGUST:

vomitings and nausea (Sr. Cr: 7.5)

SOB grade IV 

USG abd: kidney Rt - 7.7 × 3 cms

                               Lt - 6.5 × 3 xms

Grade II-III 

Gall bladder calculus, mild ascites, mild cellulitic changes over anterior abd wall. 

Hb: 6.5

Cr: 7.5

19 sessions of dialysis done outside.

PAST HISTORY:

K/c/o DM type I since 20 years and on Inj. Mixtard

H/o asthma since 20 years

H/o 5 PRBC transfusions one month ago

Not k/c/o HTN, TB, CAD, thyroid, epilepsy 

PERSONAL HISTORY:

Married

Appetite: lost since one month

Diet: mixed

Bowel and bladder movements: irregular 

Addictions: Toddy since 30 years, stopped drinking 2 years ago. 

Menstrual  history: 15 days/month 

                                   2 cycles

VITALS: 

Temp: afebrile 

BP: 70/50 mm Hg

PR: 90 bpm 

RR: 24 cpm

SpO2: 99% 

GRBS: High

GENERAL EXAMINATION:

Patient - irritable

Not oriented time, place

Oriented to person

Moderately built and nourished

Pallor + 

Oedema + 

B/L pitting type upto knee

No icterus, cyanosis, clubbing, lymphadenopathy

SYSTEMIC EXAMINATION:

CVS: s1, s2 heard. No thrills, no murmurs 

RS: BAE +

P/A: obese, soft, non tender, bowel sounds +

CNS: patient is iritable

No signs if meningeal irritation 

          

                     Right       Left

Tone    UL  normal   normal

             LL  normal   normal

Power  UL    5/5         5/5

              LL    5/5         5/5

Reflexes

              B-       +              +

              T-        -               - 

              S-        -               - 

              K-       +              +

              A-        -               - 

              P-    flexed     flexed 

INVESTIGATIONS:

— ECG

 

— 

— Serum electrolytes 

— Serum creatinine, blood urea

— Serum Iron

— ABG

— Blood grouping and Rh typing : B +ve

PROVISIONAL DIAGNOSIS:

Altered sensorium under evaluation (metabolic > organic) 

K/c/o DM- II since 20 yrs with uncontrolled sugars, HTN

? Diabetic nephropathy

SOAP NOTES:

Day zero:

SUBJECTIVE:

Altered sensorium 

OBJECTIVE:

Pt is drowsy, irrelevant sounds

BP: 90/60 mm Hg

PR: 94bpm

GRBS: high

CVS: s1, s2 heard

CNS: not oriented to time, place

         Oriented to person

RS: NVBS +

P/A: soft

ASSESSMENT:

Altered sensorium under evaluation (metabolic > organic) 

K/c/o DM- II since 20 yrs with uncontrolled sugars, HTN

? Diabetic nephropathy

TREATMENT: 

1) IVF NS, RL @ 20 ml/kg/hr - - - 10 ml/kg/hr

2) Inj. NaHCO3 100 mEq IV/Slow over 15 mins 

3) Inj. PANTOP 40 mg IV/OD

4) Inj. ZOFER 4 mg/IV/SOS

5) Inj. OPTINEURON 1 amp in 100 ml NS/slow IV/OD

6) Inj. HAI 1ml in 36 ml NS @12 ml/hr 

7) GRBS hrly 

8) I/O charting 

9) monitor vitals 2nd hrly

Day one:

SUBJECTIVE:

Altered sensorium 

OBJECTIVE:

Pt is drowsy, irritable

Temp: afebrile

BP: 150/70 mm Hg

PR: 114 bpm

GRBS: 143 mg/dl

I/O: 500/200

CVS: s1, s2 heard

CNS: not oriented to time, place

         Oriented to person

RS: NVBS +

P/A: soft

ASSESSMENT:

Altered sensorium under evaluation (metabolic > organic) 

K/c/o DM- II/HTN/ CKD on HD with DKA

TREATMENT: 

1) RT feeds - 200 ml + protein powder 4th hrly

2) IVF - 5% D @ 150 ml/hr (if GRBS < 150 mg/dl)

3) Inj. HAI 1ml in 36 ml NS @ 4 ml/hr

4) Inj. PANTOP 40 mg IV/OD

5) Inj. ZOFER 4mg IV/TID

6) Tab. ARKAMINE 0.1 mg PO/TID

7) GRBS - hrly

8) Monitor vitals - 2nd hrly

9) I/O charting

10) Tab. NICARDIA 20 mg PO/BD

11) Inj. LASIX 20 mg PO/BD

        8am - - 4pm - - x

Day two:

SUBJECTIVE:

Decreased appetite

OBJECTIVE:

Pt is drowsy, irritable

Temp: afebrile

BP: 150/90 mm Hg

PR: 110 bpm

GRBS: 158 mg/dl

I/O: 3650/1000

CVS: s1, s2 heard

CNS: NAD

RS: NVBS +

P/A: soft

ASSESSMENT:

DKA 

K/c/o DM- II/HTN/ CKD on maintenance HD 

TREATMENT:

1) Inj. PANTOP 40 mg IV/OD

2) Inj. ZOFER 4 mg IV/TID

3) Inj. LASIX 20 mg PO/BD

     8 am - - 4 pm - - x

4) Tab. NICARDIA 20 mg PO/BD

5) Tab. ARKAMINE 0.1 mg PO/OD

6) Inj.    8am   2pm   8pm

    HAI     15      10       10

    NPH    12       x        10

7) GRBS 7. profile

8) VITALS - 4TH HRLY

9) I/O CHARTING 

Day three:

 

SUBJECTIVE:

fever of one episode yesterday 

Decreased appetite 

No nausea, vomiting 

Generalised weakness

OBJECTIVE:

Pt is c/c/c 

Temp: 96.9 °F

BP: 140/70 mm Hg

PR: 87 bpm

RR: 21 cpm

I/O: 2650/1000

CVS: s1, s2 heard

CNS: NAD

RS: NVBS +

P/A: soft

ASSESSMENT:

DKA (resolved) 

K/c/o DM- II/HTN/ CKD on HD

Diabetic Nephropathy

TREATMENT: 

1) FLUID RESTRICTION < 1.5 L/day

2) SALT RESTRICTION < 2gm/day

3) Inj. PANTOP 40 mg IV/OD

4) Inj. ZOFER 4 mg IV/TID

5) Tab. NICARDIA 20 mg PO/BD

6) Tab. ARKAMINE 0.1 mg PO/OD

7) Syp. ARISTOZYME 15 ml PO/TID

8) Inj.   8am 2pm 8pm

    HAI    8      8      8

    NPH   8      x      8

Inform GRBS

9) GRBS 7. profile

10) VITALS 4TH HRLY

11) I/O CHARTING

12) Tab LASIX 20 mg PO/BD

        8 am  - -   4pm   - - x

       40 mg - - 40 mg  - - x

Day four:

SUBJECTIVE:

Pain abdomen since yesterday 

Stools not passed

OBJECTIVE:

Pt is c/c/c

Temp: afebrile

BP: 140/80 mm Hg

PR: 84 bpm

RR: 21 cpm

I/O: 950/800

CVS: s1, s2 heard

CNS: NAD

RS: NVBS +

P/A: soft

ASSESSMENT:

DKA (resolved) 

K/c/o DM- II/HTN/ CKD on HD

With Diabetic Nephropathy

With hypertensive retinopathy 

With anemia secondary to ? Iron deficiency 

TREATMENT: 

1) FLUID RESTRICTION < 1.5 L/day

2) SALT RESTRICTION < 2gm/day

3) Inj. PANTOP 40 mg IV/OD

4) Inj. ZOFER 4 mg IV/TID

5) Tab. NICARDIA 20 mg PO/BD

6) Tab. ARKAMINE 0.1 mg PO/OD

7) Syp. ARISTOZYME 15 ml PO/TID

8) Inj. HAI acc to sliding scale

    8 am - - 2 pm - - 8 pm s/c

    Inform GRBS

9) GRBS 7. profile

10) VITALS 4TH HRLY

11) I/O CHARTING

12) Tab LASIX 20 mg PO/BD

        8 am   - - 4 pm  - - x

       40 mg - - 40 mg - - x

13) Temp. Charting