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