14 year old female with Diabetic Ketoacidosis

14 year old diabetic female with shortness of breath

July 14, 2023

This is online E log book to discuss out patients de-identified health data shared after taking his / her guardian`s informed consent. Here we discuss our individual patient`s problems through series of inputs from available global online community of experts with an aim to solve patients clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient centered online learning portfolio and your valuable inputs on comments box is welcome

Chief complaints

Rash over abdomen since 3 days

Shortness of breath since afternoon

Fever since afternoon

History of Present Illness

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 wheezing

Fever since 8 hours, high grade associated with 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:

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, eats snacks and 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 6 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 have some food

Refused to eat due to nausea 

Had Vomiting at 11 pm - watery 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 fell 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 age)

Has been on insulin treatment since then

Father underwent dialysis due to CKD 7 yrs back and died 5 yrs back


General examination 

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





Vitals:

PR : 158 bpm 

BP : 110/60 mmhg 

Temperature : 98.6 F

RR : 54 cpm

Spo2 : 98% 

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 

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: 

Renal Function Test

Liver Function Test

Complete Urine Examination

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






















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