A 14 year old female with SOB snd fever

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Patient came to casualty with

C/O:1) Shortness of breath since afternoon

        2)Fever since afternoon

        3)Rash over the abdomen since 3 days


HOPI:

Patient was apparently asymptomatic 2 hours ago then she developed SOB, sudden in onset, grade - 4. No orthopnea and PND.

No H/O chest pain, Pedal edema, palpitations, excessive sweating, giddiness and wheeze

Fever since 8 hours, high grade, a/w chills and rigor since 2 pm afternoon

Rash over the abdomen since 3 days, no itching or redness, watery discharge. Applied crushed paracetamol tablet on the rash



No H/O , loose stools, pain abdomen, giddiness. 


Dialy routine of patient : 

Wakes up at 6 am in the morning 

Takes insulin at 7:15 am( 4 units of isophane and 6 units of HAI) and eats breakfast at 7:40 am

Starts to school at 7:50 am (travels via grandfather's bike) 

Has Lunch at 12:30 pm

Comes home at 5 pm and eats snacks

Goes to tution from 5 - 8 pm

Takes insulin at 8:15 pm (4 units of isophane and 6 units of HAI) and eats at around 8:40 pm 

Sleeps at around 10 pm

Events on 13-07-23 : 

Woke up at 7 am 

Missed the morning dose of insulin and breakfast because she was late to school 

Went to school at 8 am 

Felt giddiness and told the  Teacher about it. Teacher asked her to eat. 

Refused to eat due to nausea 

Had Vomiting at 11 pm - water content 

At 12:30 vomited once again - water content 

Informed her grandfather and went home at 1 pm

At home she started developing SOB so didn't eat again

Went to local doctor due to SOB  at 5 pm

She was put on O2 there and when it didn't resolve the doctor advice to go to higher centre 

Came to kamineni at 7:30 pm 

Past history :

Patient is known case of Type 1 DM since 3 yrs.

 Diagnosed 3 yrs before when she complained of polyuria.

After diagnosis she used to take 4+4 HAI and Isophane in the morning and night. And 2+2 HAI and isophane in the afternoon. 

After one year, on a regular checkup, her sugars weren't controlled, So she was advice to take  HAI - 6 IU, Isophane - 4 IU 20 mins before eating since 2 years . 

 H/O right humerus fracture 1 year back (skid and fall from bike while going to school). Treated conservatively with cast for 1 month 

Family history : H/O Type 1 DM in father. Diagnosed at 12 years. Was on insulin treatment. 

Father was on dialysis due to CKD 7 yrs back and died 5 years back

General examination : 

No signs of pallor, icterus, cyanosis, clubbing, Lymphadenopathy and pedal edema 



Vitals on admission : 

PR : 158 bpm 

BP : 110/60 mmhg 

TEMPERATURE : 98.6 F

RR : 54 cpm

Spo2 : 98% on RA

GRBS : High 





Systemic examination :

RESPIRATORY SYSTEM EXAMINATION : 

Bilateral air entry +

Normal vesicular breath sounds 

Trachea central 

No added sounds 


CVS EXAMINATION : 

S1, S2 heard 

No murmurs 


ABDOMEN EXAMINATION : 

No tenderness 

No organomegaly

Bowel sounds - present 

Rash on the abdomen 





CNS EXAMINATION : 

Gcs - E4V5M6 (15/15)

Higher mental functions - normal 

Cranial nerve examination - normal 

Sensory and motor system normal 

No signs of meningeal irritation


Investigations :


URINE FOR KETONE BODIES : positive 


RANDOM BLOOD SUGAR : 624 mg/dl 

HEMOGRAM : 




RFT: 


LFT :



CUE:




Diagnosis : Diabetic ketoacidosis with type 1 DM


Treatment : 

1) IV fluids 40 ml bolus followed by NS 150 ml/hr 

2)INJ HAI - 8 IU / stat 

3)Inj HAI 40 IU in 39 ml NS @ 6 ml / hr (Inc/Dec according to GRBS) 

4)IV fluids - 5D @ 50 ml/hr if GRBS < 200 mg / dl 

5)Input / Output charting















Comments

  1. 13/F 9 th class student resident of narketpally came to casuality with chief complaints of shortness of breath since today afternoon

    HOPI : patient was apparently asymptomatic 3 years ago then she developed polyuria for which she went to local hospital where she was found to have diabetes and was referred to hyderabad and was found to have TYPE 1 DIABETES MELLITUS and was on insulin since then.she was on regular follow up with an endocrinologist in hyderabad and was using HAI and NPH as advised by the doctor till today.She stopped going up for regular check ups since 7 months as the patient and attenders felt that the patient is in good health condition. She was non compliant to treatment since 6 months and is not taking insulin in the afternoon since 6 months and she skipped taking insulin in the morning and afternoon since 3 days(patient was skipping her breakfast since 3 days as she is not having time.patient developed rash over the abdomen which is insidious in onset and gradually progressive not associated with any pain and itching.today morning patient skipped breakfast , lunch and skipped taking insulin.later in the afternoon she developed shortness of breath which is insidious in onset gradually progressed from grade 3 to grade 4. she developed one episode of low grade fever in the afternoon which subsided without any medication.
    no nausea no vomitings no pain abdomen
    no other complaints

    DAILY ROUTINE : wakes up at 6 am
    completes her homework takes bath and goes to school by 8.30 am ( goes to school in school bus along with her younger sister )
    generally she takes insulin and consumes breakfast( idle or dosa) and goes to school. in school she will consume lunch around 12.30 pm ( rice with curry) she stopped taking insulin as it is embarrassing for her to take insulin in school
    she will come back from school at 5.30 pm consumes rice with curry and wil get ready and goes to tution at 6 pm
    she will be back from tution around 8.00 pm
    and will consume dinner gathka / chapathis
    and goes to sleep by 9.30 pm
    patient doesnt go outside and play with friends

    past history : Known case of type 1 diabetes mellitus since 3 years on insulin
    not a known case of epilepsy, bronchial asthma , thyroid disorders

    FAMILY HISTORY :
    FATHER is diabetic ( ?Type 1 DM) diagnosed during his childhood when he was around 10 years he was on regular medication( insulin)
    He had CKD at the age of 33 years and was on dialysis for 1 year and passed away at the age of 35 years.
    he was a vegetable sellar stopped working after he developed CKD
    Mother - daily wage worker earns 350/ day
    wakes up at 6 am cooks food for the children and packs their bags and goes to work by 9 am and comes back home at 5 pm. as she is the only person to look after the household and main source of income for the family she doesn’t have much time to look after the patient’s medication and well being.
    sister - healthy
    patient lives in a joint family but they stay in a bedroom where they cook eat and sleep.
    she lives along with her grand parents and uncle, aunt and mother .
    but as they have some family issue everyone will cook in their own room but stays in the same house and shares a common hall.
    There is no financial support to the patient from anyone except her mother.
    patient school fees along with bus fees costs 20000. which is paid by her mother alone.

    general examination
    patient is concious coherent cooperative
    Bp:100/60 mmhg
    pr :150bpm
    Rr 52cpm
    grbs : HIGH
    temp :98.2
    Cvs: s1 s2 heard no murmurs
    r/s BILATERAL air entry present
    nvbs heard
    p/a : soft non tender no organomegaly
    cns : nfnd

    sir my questions in this case :

    1.Would elective intubation of this case make any difference in her outcome?

    2.will sodium bicarbonate correction be helpful ?

    3. As she is in paediatric age group if she has hyperkalemia how to correct it?will it be different from adults?

    4. she is not compliant to treatment since 6 months but she was absolutely normal all these days .what precipitated this episode of DKA ( the rash or non compaliance to treatment)

    ReplyDelete

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