A 35yr old female elog.

A case of a diabetic with breathlessness 

Note: 

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(Under the guidance of  Dr. Sai charan sir PG, and Dr.G. Kusuma ma'am  intern) 

 Patient was admitted to the hospital in the afternoon of 28th June,2021.

"Chief complaints"

• Fever and Diarrhea since 5 days( 4 to 5 times a day with blood discharge).
• Back pain( 5 days ago) with abdominal pain and chest pain.

 "History"(as told by the patient's daughter because she was unconscious  at the time) 

• The pt. was diagnosed with Type 2 Diabetes 3 years ago and was put on some oral hypoglycemic agents along with Mixtard injection( 20U-x-14U) (currently on medication) 
• The pt. had visited the hospital regularly for evaluation after she was diagnosed with the condition.She had also followed the diet prescribed by a fellow medical practioner. 
• 2 years ago she developed an infection in the little finger as it couldn't be treated,the infected area was removed.
• Back pain had occured 1 year ago for which she took antibiotics( without any prescription) which worsened the pain.
• Before visiting the OPD,  she complained of severe breathlessness and pain in the chest region.
• Her GRBS(general random blood sugar)  was 580mg/dl for which 10 units of insulin was infused. 

COURSE In hospital with intubation and CPR notes :

35  F/1/0 DM: 4 yrs on " H. MIXTARD S/c PD

(2014)

c/o fever,pain in abdomen.. Altered Sensorium(1day) vomiting, loose stools( 4 days )

Pt came to casualty @ 1:00 pm on 28/6/21 in a state of altered sensorium.

INTUBATION & CPR -

At 1:40 pm Patient Suddenly became unresponsive (Gasping) 

No recordable PR

BP-NR 

SPO2 -60% MRA

ABG showed severe M. Acidosis. 

CPR was initiated  Acc. to 2015 AHA guidelines & intubated I ET 7.0

ROSC obtained after 3 cycles of CPR & Connected to mechanical ventilator

ACMV mode

VT: 420 ml

FiO2 : 60%

RR: 14 cpm

Bp 80/50mmHg

PR -110 b/m

SPO2 98%

CVS - s1, s2 heard. 

RS -BAE bilateral air entry

NVBS heard 

Per Abdomen: Soft and tender

Family history :

        Not significant.

Medical history :

• A diabetic alone,  not a known case of hypertension,asthma or tuberculosis.
• She hasn't undergone any surgery in the past.

Drug history :

• She was on treatment for diabetes.
• Not a smoker or an alcoholic.Not a drug addict .

"General examination"

• Pallor :present(palpebral conjunctiva)
• Icterus:absent
• Cyanosis:absent
• Clubbing of extremities: absent. 
• Oedema:absent
• Lymphadenopathy:absent
• Patient was initially conscious on arrival. Later she had become unconscious. 

Vitals: 

• BP :Initially her BP was fluctuating between 80/50 and 90/40. Later she was put on Noradrenaline infusion after which her BP was stagnant at 110/90.
• RR : 36 Cycles/min.
• Pulse:86beats/min.
• Temperature : Afebrile.

Respiratory system examination :

• Normal vesicular breath sounds.
• No crackles
• No wheezing heard.
• No chest wall deformity. 

Cvs examination :

• S1 S2 heard.
• No thrills.
• Cardiac murmurs absent.  

2D echo report :

Abdominal examination :

• Soft 
• Non tender
• No palpable masses 

Cns examination :

• Unconscious / altered 
• Speech no response
• No signs of meningeal irritation
• GCS (coma scale) :E 3 V 4 M 5 ( before arrest ) 
• After arrest E 1 V T M1 

1. Yesterday also same GCS 
2. Today E1 V T M4

 

Provisional diagnosis:  DKA with AKI ( ? Pre renal) 

USG(25/06/21) - Pyelonephritis. 

 

Laboratory investigations :

ABG analysis:Day 1

Day 2)

ABG analysis

Complete blood picture 

 Liver function tests:

Kidney function tests :

Based on the above results, she was put on dialysis by afternoon 2pm. 

Day 3 

 

Day 4

Day 5

Post dialysis reports

Day 6 and 7

Bed sores

BP 150/80mmHg

PR 89c/m

Ventilator was disconnected

SpO2  98% on oxygen mask.

GCS  E4 V1 M4 

No change in treatment.

Spleen-normal

Rt. Kidney - 9x4.5cm N S/E, CMD(+), PCS(N)

IMPRESSION :

Left Kidney 13.2x7.5cm increased size, abnormal echogenicity of раrenchyma noted with Ћуро and hyper echoic regions.

However no E/O  air focii was  noted. However no e/o any abscess, Perinephric collections, mild hydronephrosis in left PCS

Aorta I.V.C. - (N)

No Ascitis 

No lymph-adenopathy

U.bladder -  normal Empty

V-U Junctions - Foley'sbulb insitu.

Uterus-Size - Pelvis couldn't be assessed 

Parenchyma with (Lt)Abnormal echogenicity, mild hydronephris ,no perinephric collections suggested 

clinical corelation to

Acute pyelonephritis

.

Day 8 - An MRI scan was done

Day 9

Day 10

Day 13

Test for ketone bodies :

Day 14 

Complete debriment upto muscle was done. 

Patient is still in a persistent vegetative state. 

No prognosis is seen. 

Have started treating her with antibiotics.

Also physiotherapy was suggested but there is no improvement in her state. 

Treatment :

Day 1

Inj. NORAD 2amp in 50ml NS

Inj. PIPTAZ 2.25gm.

Inj. DOPAMINE 2amp in 50ml

Inj. HAI 1ml in 39ml NS

 

Day 2 

Inj.HAI 1ml in 39mlNS

Inj. PIPTAZ 2.25gm.

Inj. CLEXANE 40gm. 

Iv infusion NS RL @100ml/hr.

Day 3 

Inj.HAI 1ml + 34ml NS

Inj. PIPTAZ 2.25gm

Iv infusion NS (urine output + 40ml/hr)

Inj. NORADRENALINE(2 amp+46ml NS) 

  

Day 4,5 same as day 3

Day 6

Inj. PIPTAZ

Inj. LEVOFLOX

Inj. VANCOMYCIN

Day 7 and 8 same as day 6.

Day 9

Inj. MEROPENEM

Inj. LEVOFLOX

Inj.VANCOMYCIN

Day 10 and 11 same as day 9

Day 12

Inj. MEROPENEM

Inj. FOSFOMYCIN

Inj. CLEXANE

Day 13 and day 14 same treatment as of day 12 additionally Inj. LASIX was given. 

Discharge summary :

Expected date of discharge :

 

Diagnosis :

 

Chief complaints :

• Fever and Diarrhea since 5 days( 4 to 5 times a day with blood discharge).
• Back pain( 5 days ago) with abdominal pain and chest pain.

 "History"(as told by the patient's daughter because she was unconscious  at the time) 

• The pt. was diagnosed with Type 2 Diabetes 3 years ago and was put on some oral hypoglycemic agents along with Mixtard injection( 20U-x-14U) (currently on medication) 
• The pt. had visited the hospital regularly for evaluation after she was diagnosed with the condition.She had also followed the diet prescribed by a fellow medical practioner. 
• 2 years ago she developed an infection in the little finger as it couldn't be treated,the infected area was removed.
• Back pain had occured 1 year ago for which she took antibiotics( without any prescription) which worsened the pain.
• Before visiting the OPD,  she complained of severe breathlessness and pain in the chest region.
• Her GRBS(general random blood sugar)  was 580mg/dl for which 10 units of insulin was infused. 

Family history :

        Not significant.

Medical history :

• A diabetic alone,  not a known case of hypertension,asthma or tuberculosis.
• She hasn't undergone any surgery in the past. 

Drug history :

• She was on treatment for diabetes.
• Not a smoker or an alcoholic.Not a drug addict .

"General examination"

• Pallor :present(palpebral conjunctiva)
• Icterus:absent
• Cyanosis:absent
• Clubbing of extremities: absent. 
• Oedema:absent
• Lymphadenopathy:absent
• Patient was initially conscious on arrival. Later she had become unconscious. 

Vitals: 

• BP :Initially her BP was fluctuating between 80/50 and 90/40. Later she was put on Noradrenaline infusion after which her BP was stagnant at 110/90.
• RR : 36 Cycles/min.
• Pulse:86beats/min.
• Temperature : Afebrile.

Respiratory system examination :

• Normal vesicular breath sounds.
• No crackles
• No wheezing heard.
• No chest wall deformity. 

Cvs examination :

• S1 S2 heard.
• No thrills.
• Cardiac murmurs absent.  

2D echo report :

Abdominal examination :

• Soft 
• Non tender
• No palpable masses 

Cns examination :

• Unconscious / altered 
• Speech no response
• No signs of meningeal irritation
• GCS (coma scale) :E 3 V 4 M 5 ( before arrest ) 
• After arrest E 1 V T M1 

1. Yesterday also same GCS 
2. Today E1 V T M4

Provisional diagnosis:  DKA with AKI ( ? Pre renal) 

Treatment :

Inj. NORAD 2amp in 50ml NS

Inj. PIPTAZ 2.25gm.

Inj. DOPAMINE 2amp in 50ml

Inj. HAI 1ml in 39ml NS

 

Day 2 

Inj.HAI 1ml in 39mlNS

Inj. PIPTAZ 2.25gm.

Inj. CLEXANE 40gm. 

Iv infusion NS RL @100ml/hr.

Day 3 

Inj.HAI 1ml + 34ml NS

Inj. PIPTAZ 2.25gm

Iv infusion NS (urine output + 40ml/hr)

Inj. NORADRENALINE(2 amp+46ml NS) 

Day 4,5 same as day 3

Day 6

Inj. PIPTAZ

Inj. LEVOFLOX

Inj. VANCOMYCIN

Day 7 and 8 same as day 6.

Day 9

Inj. MEROPENEM

Inj. LEVOFLOX

Inj.VANCOMYCIN

Day 10 and 11 same as day 9

Day 12

Inj. MEROPENEM

Inj. FOSFOMYCIN

Inj. CLEXANE

Day 13 and day 14 same treatment as of day 12 additionally Inj. LASIX was given. 

  

I would like to thank Dr. Rakesh sir (HOD, General Medicine) for given me this opportunity, And Dr. Sai charan sir PG and Dr. Kusuma ma'am for guiding me throughout the whole process of making an elog !