SlideShare a Scribd company logo
1 of 12
CASE DISCUSSION SESSION-3
#Clinical_PharmD_Cases
Dr. S P Srinivas Nayak,
PharmD, Rph, (MSc), (Dip.D)
Assistant Professor,
Dept of Pharmacy Practice
WATCH COMPLETE LECTURE IN U TUBE CHANNEL
‘DR SP NAYAK MED EASY’
CASE – 1. 94
• An 80-year-old patient with a history of Type II diabetes mellitus is admitted to
hospital after an episode of vomiting and diarrhoea, followed by increasing
confusion and drowsiness. His medication includes HYDROCHLORTHIAZIDE and
GLYMEPRIDE. On examination he has a reduced level of consciousness, is
dehydrated, and has a low blood pressure.
Biochemistry results are:
• Sodium - 158 mmol/L (136-145 mmol/L)
• Potassium - 4.6 mmol/L (3.5-5.5 mmol/L)
• Urea - 34 mmol/L (1.8 to 7.1 mmol/L)
• Creatinine - 250 μmol/L (65.4 to 119.3 μmol/L)
• RBS - 38 mmol/L (4.0 to 5.4 mmol/L)
Arterial blood gases on air:
• pH - 7.39
• pCO2 - 40 mm Hg
• Actual bicarbonate - 24 mmol/L
• pO2 – 89 mm Hg
QUESTION: What is the diagnosis and Give Management
• 1 mmol/L equals approximately 18.01 mg/dL
to convert from mg/dL to mmol/L, value needs
to be multiplied by 0.0555
• The formula to convert µmol/L to mg/dL is 1
Micromole per Liter = 0.0113096584483149
mg/dl
Ans: Hyperosmolar hyperglycaemic
state(HHS)
• Hyperglycaemia is the main cause leading to
dehydration due to osmotic diuresis which, if severe,
results in hyperosmolarity. In HHS, unlike diabetic
ketoacidosis, there is no significant ketone production
and therefore no severe acidosis.
• Hyperosmolarity may increase blood viscosity and the
risk of thromboembolism. Factors precipitating HHS are
infection, myocardial infarction, poor adherence with
medication regimens or medicines which cause diuresis
or impair glucose tolerance, for example,
glucocorticoids.
Diagnosis of HHS
• hyperglycaemia
• dehydration and hyperosmolarity.
• There may be a mild metabolic acidosis but without
marked ketone production.
• Conscious levels on presentation range from slight
confusion to coma. In some cases, seizures occur.
• Serum sodium and potassium levels are usually
normal but may elevate, and creatinine is high.
• The average fluid deficit is 10 L, so circulatory
collapse is common.
Treatment of HHS
• Treatment requires fluid replacement to stabilise
blood pressure and improve circulation and urine
output. Potassium may be added if required.
• Insulin treatment is started via intravenous infusion
but is not aggressive, since fluid replacement also
lowers serum glucose levels.
• Prophylaxis or treatment for thromboembolism
may also be required.
CASE - 2
• Miss Priya is a 19-year-old teenager recently
diagnosed type 1 DM. She has been admitted to
hospital with diabetic ketoacidosis (DKA), which
was precipitated by a diarrhoea and vomiting
Caused by an infection.
• On enquiry she says that she was vomiting and
not eating, hence she temporarily stopped
injecting her insulins Glargine and Glulisine
• She was normally well controlled on a basal bolus
insulin regimen comprising insulin glargine
(Lantus) at night and (Apidra) three times daily
with meals.
questions
1. What is DKA?
2. Why was it a mistake for Miss Priya not to
inject her insulin whilst she was not feeling well
enough to eat?
3. What are the initial management priorities
for patients admitted with diabetic
ketoacidosis?
1. What is DKA?
Answer. 2
2. Why was it a mistake for Miss Priya not to inject her
insulin whilst she was not feeling well enough to eat?
• This is a common misunderstanding amongst patients
and sometimes even health care professionals. When a
person is unwell, their basal insulin requirements can
often increase, despite not eating. This is because of the
stress involved and the increase in the production of
counter-regulatory hormones which increase glucose
levels.
• Patients should be counselled on what are commonly
referred to as ‘sick day rules’ and adviced to monitor
Sugar levels and ketones.
Answer. 3
3. What are the initial management priorities for
patients admitted with diabetic ketoacidosis?
• Intravenous sodium chloride 0.9% should be
started as soon as possible. A fixed rate
intravenous insulin infusion should then be
started. Current recommendations are to begin
at a rate of 0.1 units/kg. Regular hourly
monitoring of blood glucose and ketones should
be undertaken and 2-hourly monitoring of serum
potassium for the first 6 h.
please
THANK YOU
‘Regular exercise, drug adherance and diet
maintenance is must to control DM,
Complication risk is high if any one is missed
from above’.
-- Dr S P Nayak med easy lectures

More Related Content

What's hot

Diabetic nephropathy
Diabetic nephropathyDiabetic nephropathy
Diabetic nephropathyPrateek Singh
 
Hyperosmolar hyperglycaemic state
Hyperosmolar  hyperglycaemic  stateHyperosmolar  hyperglycaemic  state
Hyperosmolar hyperglycaemic stateDr. Tanmoy Roy
 
case presentation: generalized edema
case presentation: generalized edemacase presentation: generalized edema
case presentation: generalized edemaFatima Siddiqui
 
Membranous nephropathy
Membranous nephropathyMembranous nephropathy
Membranous nephropathyVishal Golay
 
CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)
CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)
CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)Aaromal Satheesh
 
Diabetic Ketoacidosis management update
Diabetic Ketoacidosis management updateDiabetic Ketoacidosis management update
Diabetic Ketoacidosis management updateSCGH ED CME
 
chronic kidney disease case presentation
chronic kidney disease case presentationchronic kidney disease case presentation
chronic kidney disease case presentationKamal Sharma
 
Proteinuria how to approach final
Proteinuria   how to approach finalProteinuria   how to approach final
Proteinuria how to approach finalSachin Verma
 
pathophysiology and therapy of diabetic nephropathy
pathophysiology and therapy of diabetic nephropathypathophysiology and therapy of diabetic nephropathy
pathophysiology and therapy of diabetic nephropathyMuhamed Al Rohani
 
Glomerulonephritis Case Presentation
Glomerulonephritis Case PresentationGlomerulonephritis Case Presentation
Glomerulonephritis Case PresentationRhea Marcano
 

What's hot (20)

Diabetic nephropathy
Diabetic nephropathyDiabetic nephropathy
Diabetic nephropathy
 
Hyperosmolar hyperglycaemic state
Hyperosmolar  hyperglycaemic  stateHyperosmolar  hyperglycaemic  state
Hyperosmolar hyperglycaemic state
 
case presentation: generalized edema
case presentation: generalized edemacase presentation: generalized edema
case presentation: generalized edema
 
Membranous nephropathy
Membranous nephropathyMembranous nephropathy
Membranous nephropathy
 
CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)
CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)
CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)
 
DKA
DKADKA
DKA
 
Diabetic Ketoacidosis management update
Diabetic Ketoacidosis management updateDiabetic Ketoacidosis management update
Diabetic Ketoacidosis management update
 
Acute kidney injury
Acute kidney injuryAcute kidney injury
Acute kidney injury
 
chronic kidney disease case presentation
chronic kidney disease case presentationchronic kidney disease case presentation
chronic kidney disease case presentation
 
DKA
DKADKA
DKA
 
Hyperosmolar hyperglycemic state
Hyperosmolar hyperglycemic stateHyperosmolar hyperglycemic state
Hyperosmolar hyperglycemic state
 
Proteinuria how to approach final
Proteinuria   how to approach finalProteinuria   how to approach final
Proteinuria how to approach final
 
Acute Nephritic Syndromes
Acute Nephritic SyndromesAcute Nephritic Syndromes
Acute Nephritic Syndromes
 
pathophysiology and therapy of diabetic nephropathy
pathophysiology and therapy of diabetic nephropathypathophysiology and therapy of diabetic nephropathy
pathophysiology and therapy of diabetic nephropathy
 
Pancytopenia
PancytopeniaPancytopenia
Pancytopenia
 
Approach to pancytopenia
Approach to pancytopeniaApproach to pancytopenia
Approach to pancytopenia
 
Diabetic nephropathy
Diabetic nephropathyDiabetic nephropathy
Diabetic nephropathy
 
Acute kidney injury(AKI)
Acute kidney injury(AKI)Acute kidney injury(AKI)
Acute kidney injury(AKI)
 
Chronic Kidney Disease Update 2019
Chronic Kidney Disease Update 2019Chronic Kidney Disease Update 2019
Chronic Kidney Disease Update 2019
 
Glomerulonephritis Case Presentation
Glomerulonephritis Case PresentationGlomerulonephritis Case Presentation
Glomerulonephritis Case Presentation
 

Similar to Case discussion 3 HHS, DKA

Endocrine Emergencies.pptx
Endocrine Emergencies.pptxEndocrine Emergencies.pptx
Endocrine Emergencies.pptxmunriz
 
HBBBBBBBBtyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyBBBB.pdf
HBBBBBBBBtyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyBBBB.pdfHBBBBBBBBtyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyBBBB.pdf
HBBBBBBBBtyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyBBBB.pdfyaredmanhailu
 
Diabetes mellitus
Diabetes mellitusDiabetes mellitus
Diabetes mellitusjithahari
 
Metabolic-Emergencies.pptx
Metabolic-Emergencies.pptxMetabolic-Emergencies.pptx
Metabolic-Emergencies.pptxWengelRedkiss
 
In Hospital management of DMellitus- all.pptx
In Hospital management of DMellitus- all.pptxIn Hospital management of DMellitus- all.pptx
In Hospital management of DMellitus- all.pptxAbdelrahmanMokhtar14
 
Diabetic ketoacidosis: a case study
Diabetic ketoacidosis: a case studyDiabetic ketoacidosis: a case study
Diabetic ketoacidosis: a case studyLyndon Woytuck
 
Dental considerations in daibetes patient
Dental considerations in daibetes patientDental considerations in daibetes patient
Dental considerations in daibetes patientPayoj Chaudhary
 
Board review internal medicine
Board review internal medicineBoard review internal medicine
Board review internal medicineRanjita Pallavi
 
diabetes mellitus by Tushar 202345.pptx
diabetes mellitus by Tushar 202345.pptxdiabetes mellitus by Tushar 202345.pptx
diabetes mellitus by Tushar 202345.pptxTushar Mankar
 
3. Management of patients with diabetes.pptx
3. Management of patients with diabetes.pptx3. Management of patients with diabetes.pptx
3. Management of patients with diabetes.pptxDrChandiniRavikumar
 
glycemic_control_in_the_hospitalized_patient_august_2019.ppt
glycemic_control_in_the_hospitalized_patient_august_2019.pptglycemic_control_in_the_hospitalized_patient_august_2019.ppt
glycemic_control_in_the_hospitalized_patient_august_2019.pptssuser2127042
 
Acute complications of diabetes
Acute complications of diabetesAcute complications of diabetes
Acute complications of diabetesJeyadeepa Ramaraj
 
Diabetes Mellitus.pptx
Diabetes Mellitus.pptxDiabetes Mellitus.pptx
Diabetes Mellitus.pptxGhaffarAhmed9
 
dka-170312043320.pdfgghhfhdjrifgrgvfhdjfh
dka-170312043320.pdfgghhfhdjrifgrgvfhdjfhdka-170312043320.pdfgghhfhdjrifgrgvfhdjfh
dka-170312043320.pdfgghhfhdjrifgrgvfhdjfhMoviePics
 
Management of neonatal hypoglycemia ppt
Management of neonatal hypoglycemia pptManagement of neonatal hypoglycemia ppt
Management of neonatal hypoglycemia pptNiyati Das
 

Similar to Case discussion 3 HHS, DKA (20)

pancreatitis.pptx
pancreatitis.pptxpancreatitis.pptx
pancreatitis.pptx
 
Endocrine Emergencies.pptx
Endocrine Emergencies.pptxEndocrine Emergencies.pptx
Endocrine Emergencies.pptx
 
HBBBBBBBBtyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyBBBB.pdf
HBBBBBBBBtyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyBBBB.pdfHBBBBBBBBtyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyBBBB.pdf
HBBBBBBBBtyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyBBBB.pdf
 
fmx18-076-077.pdf
fmx18-076-077.pdffmx18-076-077.pdf
fmx18-076-077.pdf
 
Diabetes mellitus
Diabetes mellitusDiabetes mellitus
Diabetes mellitus
 
Metabolic-Emergencies.pptx
Metabolic-Emergencies.pptxMetabolic-Emergencies.pptx
Metabolic-Emergencies.pptx
 
Extra.pptx
Extra.pptxExtra.pptx
Extra.pptx
 
In Hospital management of DMellitus- all.pptx
In Hospital management of DMellitus- all.pptxIn Hospital management of DMellitus- all.pptx
In Hospital management of DMellitus- all.pptx
 
Diabetic ketoacidosis: a case study
Diabetic ketoacidosis: a case studyDiabetic ketoacidosis: a case study
Diabetic ketoacidosis: a case study
 
DM Evfmergencies2.ppt
DM Evfmergencies2.pptDM Evfmergencies2.ppt
DM Evfmergencies2.ppt
 
Dental considerations in daibetes patient
Dental considerations in daibetes patientDental considerations in daibetes patient
Dental considerations in daibetes patient
 
3. dka and hypoglycemia
3. dka and hypoglycemia3. dka and hypoglycemia
3. dka and hypoglycemia
 
Board review internal medicine
Board review internal medicineBoard review internal medicine
Board review internal medicine
 
diabetes mellitus by Tushar 202345.pptx
diabetes mellitus by Tushar 202345.pptxdiabetes mellitus by Tushar 202345.pptx
diabetes mellitus by Tushar 202345.pptx
 
3. Management of patients with diabetes.pptx
3. Management of patients with diabetes.pptx3. Management of patients with diabetes.pptx
3. Management of patients with diabetes.pptx
 
glycemic_control_in_the_hospitalized_patient_august_2019.ppt
glycemic_control_in_the_hospitalized_patient_august_2019.pptglycemic_control_in_the_hospitalized_patient_august_2019.ppt
glycemic_control_in_the_hospitalized_patient_august_2019.ppt
 
Acute complications of diabetes
Acute complications of diabetesAcute complications of diabetes
Acute complications of diabetes
 
Diabetes Mellitus.pptx
Diabetes Mellitus.pptxDiabetes Mellitus.pptx
Diabetes Mellitus.pptx
 
dka-170312043320.pdfgghhfhdjrifgrgvfhdjfh
dka-170312043320.pdfgghhfhdjrifgrgvfhdjfhdka-170312043320.pdfgghhfhdjrifgrgvfhdjfh
dka-170312043320.pdfgghhfhdjrifgrgvfhdjfh
 
Management of neonatal hypoglycemia ppt
Management of neonatal hypoglycemia pptManagement of neonatal hypoglycemia ppt
Management of neonatal hypoglycemia ppt
 

More from PARUL UNIVERSITY

prostate disease CASE DISCUSSION
prostate disease CASE DISCUSSIONprostate disease CASE DISCUSSION
prostate disease CASE DISCUSSIONPARUL UNIVERSITY
 
6. population pharmacokinetics
6. population pharmacokinetics6. population pharmacokinetics
6. population pharmacokineticsPARUL UNIVERSITY
 
CP and TDM unit.1 5TH YEAR NOTES
CP and TDM unit.1 5TH YEAR NOTESCP and TDM unit.1 5TH YEAR NOTES
CP and TDM unit.1 5TH YEAR NOTESPARUL UNIVERSITY
 
Individualization of dosage regimen
Individualization of dosage regimenIndividualization of dosage regimen
Individualization of dosage regimenPARUL UNIVERSITY
 
Cadiac cycle and heart sound
Cadiac cycle and heart soundCadiac cycle and heart sound
Cadiac cycle and heart soundPARUL UNIVERSITY
 
Advances in migraine therapy pedagogy session 27/11/21
Advances in migraine therapy pedagogy session 27/11/21Advances in migraine therapy pedagogy session 27/11/21
Advances in migraine therapy pedagogy session 27/11/21PARUL UNIVERSITY
 
CARDIO VASCULAR SYSTEM THE HEART
CARDIO VASCULAR SYSTEM THE HEARTCARDIO VASCULAR SYSTEM THE HEART
CARDIO VASCULAR SYSTEM THE HEARTPARUL UNIVERSITY
 
Management of Peripheral Neuropathy and Cardiovascular Effects in Vitamin B1...
Management of Peripheral Neuropathy and Cardiovascular Effects in  Vitamin B1...Management of Peripheral Neuropathy and Cardiovascular Effects in  Vitamin B1...
Management of Peripheral Neuropathy and Cardiovascular Effects in Vitamin B1...PARUL UNIVERSITY
 
31 moya moya disease ijprs
31 moya moya disease ijprs31 moya moya disease ijprs
31 moya moya disease ijprsPARUL UNIVERSITY
 
A case report on Rheumatoid Arthritis with sickle cell trait
A case report on Rheumatoid Arthritis with sickle cell traitA case report on Rheumatoid Arthritis with sickle cell trait
A case report on Rheumatoid Arthritis with sickle cell traitPARUL UNIVERSITY
 
Axial skeleton ANATOMY AND PHYSIOLOGY
Axial skeleton ANATOMY AND PHYSIOLOGYAxial skeleton ANATOMY AND PHYSIOLOGY
Axial skeleton ANATOMY AND PHYSIOLOGYPARUL UNIVERSITY
 
Histamines and antihistamine pharmacology
Histamines and antihistamine pharmacologyHistamines and antihistamine pharmacology
Histamines and antihistamine pharmacologyPARUL UNIVERSITY
 
Steroids complete lecture ppt
Steroids complete lecture pptSteroids complete lecture ppt
Steroids complete lecture pptPARUL UNIVERSITY
 
A study on the pharmacological management of mineral bone disease in chronick...
A study on the pharmacological management of mineral bone disease in chronick...A study on the pharmacological management of mineral bone disease in chronick...
A study on the pharmacological management of mineral bone disease in chronick...PARUL UNIVERSITY
 
A Retrospective Study of Clinical and Biochemical Profile in Geriatric Patien...
A Retrospective Study of Clinical and Biochemical Profile in Geriatric Patien...A Retrospective Study of Clinical and Biochemical Profile in Geriatric Patien...
A Retrospective Study of Clinical and Biochemical Profile in Geriatric Patien...PARUL UNIVERSITY
 

More from PARUL UNIVERSITY (20)

prostate disease CASE DISCUSSION
prostate disease CASE DISCUSSIONprostate disease CASE DISCUSSION
prostate disease CASE DISCUSSION
 
8. respiratory system
8. respiratory system8. respiratory system
8. respiratory system
 
7. pharmacogenetics
7. pharmacogenetics7. pharmacogenetics
7. pharmacogenetics
 
6. population pharmacokinetics
6. population pharmacokinetics6. population pharmacokinetics
6. population pharmacokinetics
 
CP and TDM unit.1 5TH YEAR NOTES
CP and TDM unit.1 5TH YEAR NOTESCP and TDM unit.1 5TH YEAR NOTES
CP and TDM unit.1 5TH YEAR NOTES
 
Individualization of dosage regimen
Individualization of dosage regimenIndividualization of dosage regimen
Individualization of dosage regimen
 
Cadiac cycle and heart sound
Cadiac cycle and heart soundCadiac cycle and heart sound
Cadiac cycle and heart sound
 
Heamopoetic system
Heamopoetic systemHeamopoetic system
Heamopoetic system
 
Advances in migraine therapy pedagogy session 27/11/21
Advances in migraine therapy pedagogy session 27/11/21Advances in migraine therapy pedagogy session 27/11/21
Advances in migraine therapy pedagogy session 27/11/21
 
CARDIO VASCULAR SYSTEM THE HEART
CARDIO VASCULAR SYSTEM THE HEARTCARDIO VASCULAR SYSTEM THE HEART
CARDIO VASCULAR SYSTEM THE HEART
 
Vasopressin PHARMACOLOGY
Vasopressin PHARMACOLOGYVasopressin PHARMACOLOGY
Vasopressin PHARMACOLOGY
 
Management of Peripheral Neuropathy and Cardiovascular Effects in Vitamin B1...
Management of Peripheral Neuropathy and Cardiovascular Effects in  Vitamin B1...Management of Peripheral Neuropathy and Cardiovascular Effects in  Vitamin B1...
Management of Peripheral Neuropathy and Cardiovascular Effects in Vitamin B1...
 
31 moya moya disease ijprs
31 moya moya disease ijprs31 moya moya disease ijprs
31 moya moya disease ijprs
 
A case report on Rheumatoid Arthritis with sickle cell trait
A case report on Rheumatoid Arthritis with sickle cell traitA case report on Rheumatoid Arthritis with sickle cell trait
A case report on Rheumatoid Arthritis with sickle cell trait
 
Appendicular skeleton
Appendicular skeletonAppendicular skeleton
Appendicular skeleton
 
Axial skeleton ANATOMY AND PHYSIOLOGY
Axial skeleton ANATOMY AND PHYSIOLOGYAxial skeleton ANATOMY AND PHYSIOLOGY
Axial skeleton ANATOMY AND PHYSIOLOGY
 
Histamines and antihistamine pharmacology
Histamines and antihistamine pharmacologyHistamines and antihistamine pharmacology
Histamines and antihistamine pharmacology
 
Steroids complete lecture ppt
Steroids complete lecture pptSteroids complete lecture ppt
Steroids complete lecture ppt
 
A study on the pharmacological management of mineral bone disease in chronick...
A study on the pharmacological management of mineral bone disease in chronick...A study on the pharmacological management of mineral bone disease in chronick...
A study on the pharmacological management of mineral bone disease in chronick...
 
A Retrospective Study of Clinical and Biochemical Profile in Geriatric Patien...
A Retrospective Study of Clinical and Biochemical Profile in Geriatric Patien...A Retrospective Study of Clinical and Biochemical Profile in Geriatric Patien...
A Retrospective Study of Clinical and Biochemical Profile in Geriatric Patien...
 

Recently uploaded

Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...
Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...
Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...Aditi Pandey i11
 
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...Rabia Malik
 
Sonia Journal club presentation (2).pptx
Sonia Journal club presentation (2).pptxSonia Journal club presentation (2).pptx
Sonia Journal club presentation (2).pptxpalsonia139
 
Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...
Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...
Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...jiyav969
 
Evidence-based practiceEBP) in physiotherapy
Evidence-based practiceEBP) in physiotherapyEvidence-based practiceEBP) in physiotherapy
Evidence-based practiceEBP) in physiotherapyNehaa Dubey
 
Tips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES examTips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES examJunhao Koh
 
Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depths
Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depthsUnveiling Alcohol Withdrawal Syndrome: exploring it's hidden depths
Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depthsYash Garg
 
HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...
HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...
HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...Ishita Kashyap
 
A thorough review of supernormal conduction.pptx
A thorough review of supernormal conduction.pptxA thorough review of supernormal conduction.pptx
A thorough review of supernormal conduction.pptxSergio Pinski
 
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptxANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptxDr. Sohan Biswas
 
5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now
5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now
5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale nowSherrylee83
 
World Hypertension Day 17th may 2024 ppt
World Hypertension Day 17th may 2024 pptWorld Hypertension Day 17th may 2024 ppt
World Hypertension Day 17th may 2024 pptdesktoppc
 
Gallbladder Double-Diverticular: A Case Report المرارة مزدوجة التج: تقرير حالة
Gallbladder Double-Diverticular: A Case Report  المرارة مزدوجة التج: تقرير حالةGallbladder Double-Diverticular: A Case Report  المرارة مزدوجة التج: تقرير حالة
Gallbladder Double-Diverticular: A Case Report المرارة مزدوجة التج: تقرير حالةMohamad محمد Al-Gailani الكيلاني
 
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS by Dr M.KARTHIK EMMANUEL
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS  by Dr M.KARTHIK EMMANUELCONGENITAL HYPERTROPHIC PYLORIC STENOSIS  by Dr M.KARTHIK EMMANUEL
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS by Dr M.KARTHIK EMMANUELMKARTHIKEMMANUEL
 
Video capsule endoscopy (VCE ) in children
Video capsule endoscopy (VCE ) in childrenVideo capsule endoscopy (VCE ) in children
Video capsule endoscopy (VCE ) in childrenRaju678948
 
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...janusa9823#S0007
 
ROSE CASE SPINAL SBRT BY DR KANHU CHARAN PATRO
ROSE  CASE SPINAL SBRT BY DR KANHU CHARAN PATROROSE  CASE SPINAL SBRT BY DR KANHU CHARAN PATRO
ROSE CASE SPINAL SBRT BY DR KANHU CHARAN PATROKanhu Charan
 
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...marcuskenyatta275
 
Let's Talk About It: Ovarian Cancer (The Emotional Toll of Treatment Decision...
Let's Talk About It: Ovarian Cancer (The Emotional Toll of Treatment Decision...Let's Talk About It: Ovarian Cancer (The Emotional Toll of Treatment Decision...
Let's Talk About It: Ovarian Cancer (The Emotional Toll of Treatment Decision...bkling
 

Recently uploaded (20)

Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...
Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...
Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...
 
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
 
Sonia Journal club presentation (2).pptx
Sonia Journal club presentation (2).pptxSonia Journal club presentation (2).pptx
Sonia Journal club presentation (2).pptx
 
Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...
Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...
Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...
 
Evidence-based practiceEBP) in physiotherapy
Evidence-based practiceEBP) in physiotherapyEvidence-based practiceEBP) in physiotherapy
Evidence-based practiceEBP) in physiotherapy
 
Tips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES examTips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES exam
 
Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depths
Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depthsUnveiling Alcohol Withdrawal Syndrome: exploring it's hidden depths
Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depths
 
HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...
HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...
HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...
 
A thorough review of supernormal conduction.pptx
A thorough review of supernormal conduction.pptxA thorough review of supernormal conduction.pptx
A thorough review of supernormal conduction.pptx
 
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptxANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
 
5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now
5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now
5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now
 
World Hypertension Day 17th may 2024 ppt
World Hypertension Day 17th may 2024 pptWorld Hypertension Day 17th may 2024 ppt
World Hypertension Day 17th may 2024 ppt
 
Gallbladder Double-Diverticular: A Case Report المرارة مزدوجة التج: تقرير حالة
Gallbladder Double-Diverticular: A Case Report  المرارة مزدوجة التج: تقرير حالةGallbladder Double-Diverticular: A Case Report  المرارة مزدوجة التج: تقرير حالة
Gallbladder Double-Diverticular: A Case Report المرارة مزدوجة التج: تقرير حالة
 
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS by Dr M.KARTHIK EMMANUEL
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS  by Dr M.KARTHIK EMMANUELCONGENITAL HYPERTROPHIC PYLORIC STENOSIS  by Dr M.KARTHIK EMMANUEL
CONGENITAL HYPERTROPHIC PYLORIC STENOSIS by Dr M.KARTHIK EMMANUEL
 
Video capsule endoscopy (VCE ) in children
Video capsule endoscopy (VCE ) in childrenVideo capsule endoscopy (VCE ) in children
Video capsule endoscopy (VCE ) in children
 
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
 
ROSE CASE SPINAL SBRT BY DR KANHU CHARAN PATRO
ROSE  CASE SPINAL SBRT BY DR KANHU CHARAN PATROROSE  CASE SPINAL SBRT BY DR KANHU CHARAN PATRO
ROSE CASE SPINAL SBRT BY DR KANHU CHARAN PATRO
 
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
 
In Kuwait Abortion pills (+918133066128)@Safe abortion pills in Kuwait City
In Kuwait Abortion pills (+918133066128)@Safe abortion pills in Kuwait CityIn Kuwait Abortion pills (+918133066128)@Safe abortion pills in Kuwait City
In Kuwait Abortion pills (+918133066128)@Safe abortion pills in Kuwait City
 
Let's Talk About It: Ovarian Cancer (The Emotional Toll of Treatment Decision...
Let's Talk About It: Ovarian Cancer (The Emotional Toll of Treatment Decision...Let's Talk About It: Ovarian Cancer (The Emotional Toll of Treatment Decision...
Let's Talk About It: Ovarian Cancer (The Emotional Toll of Treatment Decision...
 

Case discussion 3 HHS, DKA

  • 1. CASE DISCUSSION SESSION-3 #Clinical_PharmD_Cases Dr. S P Srinivas Nayak, PharmD, Rph, (MSc), (Dip.D) Assistant Professor, Dept of Pharmacy Practice WATCH COMPLETE LECTURE IN U TUBE CHANNEL ‘DR SP NAYAK MED EASY’
  • 2. CASE – 1. 94 • An 80-year-old patient with a history of Type II diabetes mellitus is admitted to hospital after an episode of vomiting and diarrhoea, followed by increasing confusion and drowsiness. His medication includes HYDROCHLORTHIAZIDE and GLYMEPRIDE. On examination he has a reduced level of consciousness, is dehydrated, and has a low blood pressure. Biochemistry results are: • Sodium - 158 mmol/L (136-145 mmol/L) • Potassium - 4.6 mmol/L (3.5-5.5 mmol/L) • Urea - 34 mmol/L (1.8 to 7.1 mmol/L) • Creatinine - 250 μmol/L (65.4 to 119.3 μmol/L) • RBS - 38 mmol/L (4.0 to 5.4 mmol/L) Arterial blood gases on air: • pH - 7.39 • pCO2 - 40 mm Hg • Actual bicarbonate - 24 mmol/L • pO2 – 89 mm Hg QUESTION: What is the diagnosis and Give Management
  • 3. • 1 mmol/L equals approximately 18.01 mg/dL to convert from mg/dL to mmol/L, value needs to be multiplied by 0.0555 • The formula to convert µmol/L to mg/dL is 1 Micromole per Liter = 0.0113096584483149 mg/dl
  • 4. Ans: Hyperosmolar hyperglycaemic state(HHS) • Hyperglycaemia is the main cause leading to dehydration due to osmotic diuresis which, if severe, results in hyperosmolarity. In HHS, unlike diabetic ketoacidosis, there is no significant ketone production and therefore no severe acidosis. • Hyperosmolarity may increase blood viscosity and the risk of thromboembolism. Factors precipitating HHS are infection, myocardial infarction, poor adherence with medication regimens or medicines which cause diuresis or impair glucose tolerance, for example, glucocorticoids.
  • 5. Diagnosis of HHS • hyperglycaemia • dehydration and hyperosmolarity. • There may be a mild metabolic acidosis but without marked ketone production. • Conscious levels on presentation range from slight confusion to coma. In some cases, seizures occur. • Serum sodium and potassium levels are usually normal but may elevate, and creatinine is high. • The average fluid deficit is 10 L, so circulatory collapse is common.
  • 6. Treatment of HHS • Treatment requires fluid replacement to stabilise blood pressure and improve circulation and urine output. Potassium may be added if required. • Insulin treatment is started via intravenous infusion but is not aggressive, since fluid replacement also lowers serum glucose levels. • Prophylaxis or treatment for thromboembolism may also be required.
  • 7. CASE - 2 • Miss Priya is a 19-year-old teenager recently diagnosed type 1 DM. She has been admitted to hospital with diabetic ketoacidosis (DKA), which was precipitated by a diarrhoea and vomiting Caused by an infection. • On enquiry she says that she was vomiting and not eating, hence she temporarily stopped injecting her insulins Glargine and Glulisine • She was normally well controlled on a basal bolus insulin regimen comprising insulin glargine (Lantus) at night and (Apidra) three times daily with meals.
  • 8. questions 1. What is DKA? 2. Why was it a mistake for Miss Priya not to inject her insulin whilst she was not feeling well enough to eat? 3. What are the initial management priorities for patients admitted with diabetic ketoacidosis?
  • 9. 1. What is DKA?
  • 10. Answer. 2 2. Why was it a mistake for Miss Priya not to inject her insulin whilst she was not feeling well enough to eat? • This is a common misunderstanding amongst patients and sometimes even health care professionals. When a person is unwell, their basal insulin requirements can often increase, despite not eating. This is because of the stress involved and the increase in the production of counter-regulatory hormones which increase glucose levels. • Patients should be counselled on what are commonly referred to as ‘sick day rules’ and adviced to monitor Sugar levels and ketones.
  • 11. Answer. 3 3. What are the initial management priorities for patients admitted with diabetic ketoacidosis? • Intravenous sodium chloride 0.9% should be started as soon as possible. A fixed rate intravenous insulin infusion should then be started. Current recommendations are to begin at a rate of 0.1 units/kg. Regular hourly monitoring of blood glucose and ketones should be undertaken and 2-hourly monitoring of serum potassium for the first 6 h.
  • 12. please THANK YOU ‘Regular exercise, drug adherance and diet maintenance is must to control DM, Complication risk is high if any one is missed from above’. -- Dr S P Nayak med easy lectures