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
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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
On16/9/21
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
On 16/9/21
SOAP NOTES
SUBJECTIVE:
Pain abdomen since yesterday
Stools passed yesterday
OBJECTIVE:
Pt is c/c/c
Temp: afebrile
BP: 100/70 mm Hg
PR: 80 bpm
RR: 21 cpm
I/O: 750/650
CVS: s1, s2 heard
CNS: NAD
RS: NVBS +
P/A: soft
ASSESSMENT:
Her GRBS at 8am was 500mg/dl and her urine ketones came positive
Started her on Insulin IV infusion
DKA
With 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) 2) SALT RESTRICTION < 2gm/day
3) 3) Inj. PANTOP 40 mg IV/OD
4) 4) Inj. ZOFER 4 mg IV/TID
5) 5) Tab. NICARDIA 20 mg PO/BD
6) 6) Tab. ARKAMINE 0.1 mg PO/OD
7) 7) Syp. ARISTOZYME 15 ml PO/TID
8) 8) Inj. Insulin 1 amp in 39 ml/NS@4ML/ HR
9) GRBS hourly
10) VITALS 4TH HRLY
11) I/O CHARTING
12) Tab LASIX 20 mg PO/BD
13) Temp. Charting
