DKA

This is a case of a 14 year old girl who came with chief complaints of:


Shortness of breath since 2 days

Fever since 1 day

Abdominal pain since 1 day

Vomiting 1 episode


HOPI: 

The patient was apparently asymptomatic  2 days ago then she developed sudden onset shortness of breath since 2 days, gradually progressive and progressed to stage 4. Shortness of breath started after patient missed taking 2 doses of insulin. No orthopnea, no PND. 

Fever since 1 day, high grade associated with chills and rigors, relieved on taking medication, no diurnal variation.

Abdominal pain since 1 day epigastric region alter progressed to diffuse abdominal pain.

No h/o vomiting, loose stools, giddiness.

Headache present, vomiting 1 episode- non projectile, not blood stained, content- food material.


Past history 

H/o type 1 DM since 4 years in biphasic insulin 30/70(17U-12U)

h/o 2 previous admissions for fever in last 4 years


Family history

h/o diabetes in younger sister from 6 years of age
H/o DM in her grandfather from many years


Personal history

•She's a 9th class student
•Diet mixed
•Appetite normal
•Non vegetarian
•Bowel and bladder movements are regular
•Sleep adequate
•Menarche not attained
•No allergies
•No habits or drug addictions



GENERAL EXAMINATION


•Patient is conscious coherent and cooperative. Well oriented to time place and person. 

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


Vitals

Pulse - 98 bpm

BP - 120/80 mm Hg

RR - 28 count

Temp- 99.1F

SpO2- 98%

GRBS- 526mg%

CVS:


Inspection:


•There are no chest wall abnormalities 
•The position of the trachea is central. 
•Apical impulse is not observed. 
•There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 


Palpation:

•Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 
•Position of trachea was central 
•There we no parasternal heave , thrills, tender points. 



Auscultation: 

•S1 and S2 were heard 
•There were no added sounds / murmurs. 


Respiratory system:

(( I ))
•Chest - symmetrical
•Trachea - central
•Apical impulse
•No drooping of shoulder
•No intercostal indrawing
•No supraclavicular hallowness
•Shape and symmetry of the chest normal.
•No dilated veins. 
•No visible scars.

(( P ))
• Postion of trachea - midline / central
•Confirmation of apical impulse - 
•Symmetry of anterior posterior and upper thoracic of both sides are symmetrical 
• vocal fremitus -on palpation of right and left sides in all the areas vibrations are normal on both sides. 

((P))
• supraclavicular , infraclavicular, mammary , axillary,infra axillary , suprascapular, interscapular, infrascapular all nine areas are equally herad on both sides
• On tidal percussion resonant sound was heard

((A))
• Vesicular breath sounds heard 
• vocal resonance equally heard on both sides

Bilateral air entry is present 


Per Abdomen:


•Shape is scaphoid
•Abdomen is soft and non tender with no signs of organomegaly
•Bowel sounds are heard

PROVISIONAL DIAGNOSIS 

Diabetic ketoacidosis secondary to non compliance

k/c/o DM1 since 4 years


Investigations 
 On complete urine examination : ketone bodies were seen
On CBP : blood sugar levels increased as she didn't take insulin injections for two days

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