A 26 year old male patient was admitted to the male medicine ward with complaints of nausea, vomiting, generalised weakness, anxiety, decreased appetite, headache since noon.

1. DIABETES
MELLITUS
TYPE 1 WITH
DIABETIC
KETOACIDOSIS
• AJITA SADHUKHAN
• PHARM D 4TH YEAR
• ROLL No. – 1
• ENROLLMENT No. - 150821207001
26-03-2020
1

2. SUBJECTIVE EVIDENCE :-
Patient’s Name Moin Khan
Patient IPD No. 18021434
Department Male Medicine Ward/ Intensive Care Unit
Unit II
Age 26 years
Gender Male
Weight 45 Kg
Date of Admission 23.11.18
Date of Discharge 30.11.18
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3. Reason for admission :
C/O:
- Nausea
- Vomiting
- Generalized weakness
- Anxiety
- Decreased appetite
- Headache since today noon
Past Medical History : k/c/o DM I
Past Medication History :
- Inj. H. Mixtard SC 28 units BBP × 11 months
- Inj. H. Mixtard SC 24 units BD
Family and Social History :
Family History: Insignificant
9th std. student
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Temperature: normal
Pulse: 126 bpm
Respiration: normal
B.P.: 130/80 mm Hg
SpO2: 98%
RS: AEBE clear
CVS: S1 S2 heard
CNS: NAD
PA: soft
RBS: 400 mg/dL
Nutrition: Poor
Appetite: Decreased
Bowel + Bladder habits: Regular
Previous Allergies: NKA
Pallor: +

4. Complete Blood Count (23.11.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Hb 14.6 12.5-16 g/dL
WBC 7310 4000-10500 /mcgL
Neutrophils 71 50-70 %
Eosinophils 01 0-7 %
Lymphocytes 24 20-40 %
Monocytes 04 <10 %
Basophils 00 <1 %
RBC 5.5 4.20-5.40 Millions/mcgL
MCH 48.2 27-31 pg
Platelets 275000 1.5-4.5*10^5 /mcgL
MCV 87.6 78-100 fL
Hematocrit (PCV) 26.5 37-47 %
MCHC 30.3 32-36 g/dL
RDW-CV 12.3 11-14.6 %
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5. LIVER FUNCTION TEST: (23.11.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Se. Creatinine 1.0 Up to 1.5 Mg/dL
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Na+ 136 130-145 mEq/L
K+ 5.2 3.5-5.1 mEq/L
Cl- 98 98-106 mEq/L
HCO3- 16.8 24-36 mEq/L
Others:
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
S.G.P.T (ALT) 35 0.0-49 U/L
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SERUM ELECTROLYTES: (23.11.2018)

6. BLOOD GLUCOSE: (24.11.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
K+ 3.1 3.5-5.1 mEq/L
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
HbA1C 13.7 6-8 %
Mean blood glucose 343.8 70-130 Mg/dL
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SERUM ELECTROLYTES: (24.11.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
K+ 3.2 3.5-5.1 mEq/L
SERUM ELECTROLYTES: (25.11.2018)

7. Complete Blood Count (26.11.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Hb 13.4 12.5-16 g/dL
WBC 7200 4000-10500 /mcgL
Neutrophils 27 50-70 %
Eosinophils 03 0-7 %
Lymphocytes 64 20-40 %
Monocytes 06 <10 %
Basophils 00 <1 %
RBC 4.95 4.20-5.40 Millions/mcgL
MCH 43.1 27-31 pg
Platelets 232000 1.5-4.5*10^5 /mcgL
MCV 87.1 78-100 fL
Hematocrit (PCV) 27.1 37-47 %
MCHC 31.1 32-36 g/dL
RDW-CV 12.0 11-14.6 %
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8. LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Se. Creatinine 0.8 Up to 1.5 Mg/dL
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
Na+ 141 130-145 mEq/L
K+ 4.2 3.5-5.1 mEq/L
Cl- 102 98-106 mEq/L
HCO3- 26.5 24-36 mEq/L
Others:
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SERUM ELECTROLYTES: (26.11.2018)
BLOOD GLUCOSE: (26.11.2018)
LABORATORY
PARAMETERS
OBSERVED VALUE NORMAL RANGE UNIT
HbA1C 13.1 6-8 %
Random blood glucose 480 150-200 Mg/dL

9. • 23.11.2018
1. ECG: Sinus Tachycardia
2. Arterial Blood Gas:
a. pH: 7.07 (↓)
b. pCO2: 18.1 mmHg (↓)
c. pO2: 126 mm Hg (↑)
d. cK+: 6.06 m mol/L (↑)
e. cCa2+: 4.23 m mol/L (↓)
f. cHCO3- (p): 5.0 m mol/L
• 24.11.2018
1. Urine Analysis:
a. Physical Examination:
i. Colour : Pale yellow
ii. Appearance: Hazy
iii. Reaction: 6.0
iv. Specific gravity: 1.030
b. Chemical Examination:
i. Glucose: Trace
ii. Ketone: 1+
c. Microscopic Examination: normal
2. Arterial Blood Gas:
a. pO2: 104 mm Hg (↑)
b. pNa+: 149 m mol/L (↑)
c. cK+: 2.81 m mol/L (↓)
d. cCa2+: 4.07 m mol/L (↓)
3. Urinary Acetone: +
4. USG KUB: No significant abnormality
• 27.11.2018
Random blood glucose (150-200 mg/dL) : 324
• 28.11.2018
Random blood glucose (150-200 mg/dL) : 336
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10. ASSESSMENT
• Provisional Diagnosis: epilepsy with 2½ months of
amenorrhoea
• Justification:
• A 16 year old male patient was admitted to male
medicine ward unit 2 with complaints of nausea,
vomiting, generalized weakness, anxiety, decreased
appetite and headache since today noon. The patient is a
k/c/o Diabetes Mellitus Type 1 since 11 months.
• Based on subjective evidence, past medical history and
objective evidence, the patient was diagnosed with
Diabetes Mellitus Type 1 with Diabetic Ketoacidosis.
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Final Diagnosis:
• Diabetes Mellitus
Type 1 with
Diabetic
Ketoacidosis

11. GOALS OF TREATMENT
• Ameliorate symptoms.
• Reduce the risk of microvascular and macrovascular complications.
• Reduce mortality.
• Improve the quality of life.
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12. TREATMENT OPTIONS
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13. MONITORING PARAMETERS
❑Disease related : ❑Drugs related :
• Ondansetron: ECG
• Ceftriaxone: RFT, white blood cell count,
differential count.
• Paracetamol: fever reduction
• Pantoprazole: Se. Mg2+, Vitamin B12
• Glargine: HbA1C, Blood Glucose, Se. K+
• H.A.I: HbA1C, Blood Glucose
• Sodium Bicarbonate: Blood pH, arterial blood
gases, total CO2, urinard pH, serum electrolytes,
serum osmolality, blood glucose, renal function,
urinary chloride, EKG, Blood pressure
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14. Day 1: 23.11.18 (ICU)
• Temp. normal
• Pulse: 108 bpm
• BP: 116/80 mm Hg
• SPO2: 99% @ RA
• RS: AEBE clear
• CVS: S1, S2 heard
• CNS: Conscious and oriented
• No sign of diabetic retinopathy.
• Adv.: Regular fundus every yearly
or SOS if develop decrease in
vision
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Day 2: 24.11.18 (ICU)
• GC: poor
• Temp. normal
• Pulse: 90 bpm
• BP: 110/70 mm Hg
• SPO2: 97% @ RA
• RS: AEBE clear
• CVS: S1, S2 heard
• CNS: Conscious and oriented
• P/A: soft
• UOP: 1400 cc
• Urine: ketone +

15. Day 3: 25.11.18
• GC: stable
• Temp. normal
• Pulse: 70 bpm
• BP: 100/70 mm Hg
• SPO2: 98% @ RA
• RS: NAD
• CVS: NAD
• CNS: Conscious and oriented
• P/A: soft
• I/O: 3656/1500 mL
• Urine: Passed
• Stool: Not passed
• Adv.: PL, PP2BS, RBS, food diet
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Day 4: 26.11.18
• GC: stable
• Temp. normal
• Pulse: 78 bpm
• BP: 100/70 mm Hg
• SPO2: 98%
• RS: NAD
• CVS: NAD
• CNS: Conscious and oriented
• P/A: soft
• UOP: 800 mL
• RBS: 78 mg/dL
• Adv.: shift to ward

16. Day 5: 27.11.18
• Temp. 97ºF
• Pulse: 86 bpm
• Respiration: 20 breaths/min
• BP: 140/90 mm Hg
• SPO2: 97%
• RS: NAD
• CVS: NAD
• CNS: NAD
• RBS: 123 mg/dL
• Adv.: Endocrine ref., urine ketone 6
hourly, FBS,PL, PP2BS, pO2, pCO2
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Day 6: 28.11.18
• Temp. normal
• Pulse: 75 bpm
• Respiration: normal
• BP: 140/80 mm Hg
• SPO2: 98%
• RS: NAD
• CVS: NAD
• CNS: NAD
• RBS: 259 mg/dL
• Adv.: Ref. to DKA, endocrine reference
today

17. Day 7: 29.11.18
• Temp. normal
• Pulse: 79 bpm
• BP: 110/80 mm Hg
• SPO2: 98%
• RS: NAD
• CVS: NAD
• CNS: NAD
• Urine/Stool: Passed
• FBS: 196 mg/dL
• RBS: 196 mg/dL
• PP2BS: 185 mg/dL
• PL: 166 mg/dL
• Adv.: DKA ref.
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Day 8: 30.11.18
• Temp. normal
• Pulse: 80 bpm
• BP: 120/90 mm Hg
• SPO2: 96%
• RS: NAD
• CVS: NAD
• CNS: NAD
• RBS: 75 mg/dL
• Urine/Stool: passed
• Adv.: plan discharge, RBS monthly,
follow-up after 15 days.

18. Day-wise Medication Chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS 1 2 3 4 5 6 7 8
Inj.H.A.I 10-8-14 units
(BBF-BL-BD)
SC 30 min before meal DM I + DKA
√ √ √ √ √ √
Inj.Glargine 12 units SC @ 10:00 p.m. DM I + DKA √ √ √ √
Inj. Pantoprazole 40 mg IV BD Gastric disturbance √ √ √ √ √ √ √ √
Inj. Ondansetron 4 mg IV SOS (TDS) Prevents emesis √ √ √ √ √ √ √ √
Inj. NS 500 mL IV 100 mL/hrly Electrolyte balance √ √
Inj. RL 500 mL IV - Fluid replacement √
Inj. H.A.I 20 units SC - DM I + DKA √
Inj. Paracetamol 1 @ IV SOS Fever √
Inj. Ceftriaxone dil. 1 g IV BD Antibacterial prophylaxis √ √ √ √ √ √ √ √
Inj. H.A.I 16-16-16 units SC BBF-BL-BD DM I + DKA √ √ √ √
Inj. Glargine 16 units SC @ 10:00 p.m. DM I + DKA √ √ √ √
Inj. NaHCO3 200 mL IV @ 6 mL/hr stat Acid-base balance √
Adv.: FD + ADD

19. Discharge Medication Chart
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Adv.: (i) Take the above medications for 15 days
(ii) Follow-up after 15 days
(iii) RBS monthly
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj.H.A.I 12-12-12 units SC BBF-BL-BD DM I + DKA
Inj.Glargine 18 units SC @ 10:00 p.m. DM I + DKA

20. GOALS ACHIEVED
• No fresh complaints
• Patient feels better
• No nausea and vomiting
• Vitals stable.
• General condition fairly better.
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21. PATIENT COUNSELLING
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• ABOUT DISEASE:
• Diabetic ketoacidosis happens when your blood sugar
(glucose) goes up too high because you are low on
insulin . A high blood sugar can make you pass a lot of
urine, which leads to dehydration.
• In DKA, the body burns fat, which increases a toxic
substance call ketones in the blood.
• DKA happens mostly in children or adults with type 1
diabetes mellitus.
• It is usually brought on by an illness, or by missing doses
of diabetes medication.
• It is a major medical emergency and remains a serious
cause of morbidity, especially in patients with type 1
diabetes and must be treated right away. If not treated
right away, it can cause coma or death.
• But it is preventable with proper adherence to therapy.

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• ABOUT DRUGS:
1. Insulin Glargine and Actrapid, both are used to lower blood sugar levels.
2. They should be injected under the skin (SC inj.), usually thighs, arms, buttocks or abdomen. In general, injections
into the abdomen tend to work faster than those given in other areas. You shouldn’t massage the injection area
after administering the injection.
3. Each time you inject your insulin make sure you use a different site. This helps to prevent skin thickening and
pitting, which can occur if the injection is repeatedly given in the same site.
4. You should measure your blood sugar levels everyday when using insulin injections. The dose you need to inject
each time will depend on your blood sugar levels, what you are going to eat and if you have been doing or will be
doing exercise.
5. Your insulin requirements may increase if you are ill, especially if you have fever. Your insulin dose also needs
adjusting during periods of emotional disturbance, or if you increase your physical activity or change your usual
diet.
6. To gain the most benefit, do not miss doses.

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WARNING!!!
1. Low blood sugar (hypoglycaemia) is a potential side effect of insulin therapy. Other side effects include upset
stomach or throwing up and weight gain. Symptoms of hypoglycaemia often occur suddenly and may include cold
sweats, cool pale skin, tremor, anxiety, unusual tiredness or weakness, confusion, difficulty in concentration,
excessive hunger, temporary vision changes, headache, nausea and palpitations. Always keep a source of sugar
handy for times when your blood sugar gets too low.
2. Your ability to concentrate or react may be reduced if you have low blood sugar, so take precautions when driving.
3. You should change your insulin only on your doctor’s advice.
4. Do not use your insulin if it becomes cloudy or has particles in it.
5. Do not start new prescription, over-the-counter medicines, or herbal and dietary supplements without telling your
doctor.
6. It is a good idea to wear a medical alert bracelet stating you are on insulin.
STORAGE!!
1. Before use, the vials should be stored in a refrigerator at 2-8˚C. Do not freeze. Keep the vial in the outer carton in
order to protect from light. Once in use, the vial should be kept out of the fridge, below 25˚C. It can be used for
upto six weeks, again, keep it in the outer carton to protect it from light.

24. •LIFESTYLE MODIFICATIONS:
1. Limit or avoid drinking alcohol such as beer, wine, or mixed drinks.
2. Deink enough fluids to keep your urine light yellow in colour.
3. Lose weight if you need to and keep a healthy weight.
4. Take proper care of skin and foot everyday.
5. Check your feet and lower legs for red skin areas and open sores.
6. Wear comfortable well-fitting shoes to prevent foot injury.
7. Break in new shoes gradually.
8. Learn how to trim your toenails properly.
9. Its also good for your family to learn about diabetes. Make sure your family
members know what to do if your sugar is too high or too low.
10. Find ways to make your life less stressful.
11. Having diabetes or complication of diabetes can be scary or depressing. You
may wish to talk with a therapist about your feelings.
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26. REFERENCES :
• A textbook of Pharmacotherapy : By Joseph P. Dipiro and Robert L.
Talbert, 7th Edition, Mc-Graw Hill Publications
• Medscape
• Cims
• Micromedex
• Mayoclinic.com
• Davidson’s Principles and Practice of Medicine 21st Edition
• www.netdoctor.co.uk
• American Diabetes Association (2012)

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