DKA case presentation in Benadir hospital

1. Case presentation
 presenter: Dr.Abdirazaaq Ali Yusuf
 Tutor: Dr. Mohamed Abdirahman Omar
“Dr.Qalbi”
CO-Tutor: Dr.Nuradiin Mohamed
Hussien

2. Personal data
Sharmake Abdulkadir Ali 15yrs old
male from Daayniile is admitted on
12/08/2020 11:30am in ER
Inforned by him self.
DOHX:1 3 /0 8 /2 0 2 0

3. Main complain
 Increased in urination for 4 days.
 Abdominal pain for 12 hours

4. History of presenting illness
 The patient is a known case of type1
diabetes diagnosed 2yrs ago with insulin
treatment.
 The patient presents gradual increasing
urination, he also presented increased
amount of urine and increased frequency
6/12 and associates with excess drinking
water and excess thirst.

5. HPI cont……..
 In the midnight patient developed
cramp-like Epigastric pain, acute in
onset, 3 hours duration, dull in
character, Not radiating, no
aggravating or relieving factors,
associated with nausea and vomiting
non projectile one times, containing
food particles and odorless, colorless

6. Systemic review
 Ear: bilateral yellowish discharge &
sometimes difficult hearing.
 SKIN& MS: scar in insulin injected
area.
 All other systems are unremarkable.

7. PAST MEDICAL HISTORY
 Patient is diagnosed:
 Gastritis 4 months ago at AL BIRI HOSPITAL
 Cholesterol 1 year ago at AL BIRI HOSPITAL
 Type 1 Dm two year ago FIQHI HOSPITAL
 TB 6months ago at GENTELMAN HOSPITAL
 One time hospitalization for DKA in FIQHI
HOSPITAL .
 No previous surgery
 No history of transfusion

8. Drug history
 No known drug allergy
 On month TB treatment then stopped.
 Gastritis treatment
 Insulin therapy two times a day for one month.
 AMPICILLIN 500mg uses ulcers at insulin
injected area.
 over counter drug use.
Omeperazole 40mg for heartburn
Paracetamol 500mg for headache

9. Nutrition history
 BEFORE ILLNESS:
the patient had good appetite and has been taking
regular food with the family.
AFTER ILLNESS:
Last 6 hours the patient was poor apatite (Anorexic)
then after hospitalization the patient eats
everything.
 Interpretation: poor diet control.

10. Family history
 Mother died “ “‫يرحمها‬ ‫هللا‬ for hepatocellular
carcinoma.
 Father live work at food equipment
 Grandfather has DM
 Siblings: 6
2 brothers in mother and 2 brother+ 2sister in
father.
 No similar condition in the family
 No bad habit in the family

11. Growth History
 No previous growth chart is available
 My own growth chart “CDC”
 W/A = <5 Percentile
 H/A=<5 Percentile
 BMI/A: <3rd percentile
 INTERPRETAION: underweight and stunted

12. Socioeconomic history
 Mr.sharmake is 15yrs old student in grade
6 IMAMU MALIK primary school.
 he lives with his uncle with 10 persons in
the house 4 rooms one kitchen and two
toilets
 No animal in the house
 Source of water is tape water
 Source electricity : BECO

13. Anthropometric measurement
 Weight:28kg
 Height:154cm
 BMI:11.8kg/m2
 INTERPRETATION: Underweight

14. Physical Examination
 GENERALAPPEARANCE
the patient looks ill Alert muscle wasting, bilateral tonsilar
enlargement and bilateral post auricular lymph node
palpable, bilateral yellowish ear discharge
Vital signs:
On admission on examination
T= 37.1c T=36.6
PR= 120bpm PR=91bpm
RR= 20bpm RR=22bpm
02sat= 98%
Tachycardia
Normal vital signs

15. General examinations
 Skin: Arthus reaction
 Ear :Patient has bilateral recurrent
yellowish ear discharge.
 Neck: palpable posterior auricular lymph
node.
 Throat : bilateral tonsilar enlargement.

16. Systemic examination
Musculoskeletal: muscle
wasting
All other systemic
examinations are
unremarkable

17. CASE SUMMERY
 Sharmke C.qadir Cali is 15y/o male from
Daayniile admitted on 12/08/2020 in ER presented
gradual increasing urination increased amount of
urine and increased frequency associates with
excess drinking water and excess thirst for 4
days In the midnight patient developed cramp-
like Epigastric pain, acute in onset, 3 hours
duration, dull in character, Not radiating, no
aggravating or relieving factors, associated with
nausea and vomiting non projectile one times,
containing food particles and odorless, colorless

18. Cont……
 O/E the patient looks ill Alert muscle
wasting, bilateral tonsilar enlargement
and bilateral post auriclar lymph node
palpable, bilateral yellowish ear
discharge
 Vital signs
 Temperature37.1c
 RR 20bpm PR120bpm BS. 565mg/dl

19. DIFFERENTIAL DIAGNOSIS
 Hyperosmolar hyperglycemic nonketotic
syndrome (HHNS)
 Hypoglycemia.
 Intoxication (e.g., methanol, salicylates)
 Gastroenteritis
 Starvation ketosis
 Other medical causes of acute abdomen.

20. Definitive diagnosis

21. Suspect diagnosis

22. Investigation
 URINE ANALYSIS:
PH: 5.0
Sugar: ++++
Ketone:++
 Serum blood glucose: 450mg/dl

23. I recommend
 ABG Analysis
 Electrolyte analysis
 Renal function test
 CBC

24. management
 SUPPORTIVE MANAGEMENT
 DEFINITIVE MANAGMENT

25. SUPPORTIVE MANAGEMENT
 IV CANNULA
 MONITOR BLOOD GLUCOSE

26. DEFINITIVE MANAGMENT
 Fluid
 Insulin
 Electrolyte

27. Fluid management
12/08/2020
 Bolus 20ml× kg
 Our pt is 28kg so
 29kg ×20ml= 560ml give for 2hr
 MANTAINANCE:
 ORS : 2L

28. Management cont…..
13/08/2020
 Ceftraxone injection 1g. 10ml×2 for 7days

29. 12/08/2020
Subcutaneous insulin
 The required dose of insulin is based on age
group
 Prepuberty: 0.7unit × kg
 Puberty: 1unit × kg
 Adult:1.2 × kg
 Mixed insulin ( mixtard) :21 units
 Morning:2/3 14unit S.C
 Evening: 1/3 7unit S.C
o Actrapid insulin: 2unit

30. Monitoring blood glucose 12/08/2020
TIME B/S
01:00 AM 533mg/dl
02:00AM 560mg/dl
03:00AM 200mg/dl
04:00AM 117mg/dl
05:00AM 80mg/dl
06:00AM 138mg/dl

31. Monitoring blood glucose 13/08/2020
TIME B/S Insulin unit
09:00 AM 436mg/dl
10:00AM 449mg/dl
0700PM HI 3 unit actirapid
10:00PM 365mg/dl
11:00PM 448mg/dl

32. Monitoring blood glucose 14/08/2020
TIME B/S Insulin unit
03:00 AM 360mg/dl
06:00AM 542mg/dl
0900AM 542mg/dl 3 unit actirapid
10:50AM 523mg/dl
11:00AM 538mg/dl 3 unit actirapid
02:00PM 447mg/dl
04:00PM HI 3 unit actirapid

33. Progressive note
 13/08/2020 the patient has sleep, urine & stool passes normally
 O/E the patient is conscious alert muscle wasting palpable bilateral post
auricular lymph nodes, bilateral yellowish ear discharge, small scar
lesion in insulin injected area, bilateral tonsilar enlargement.
 v/s: pulse: 96bpm RR:18bpm
 Assessment: C.O.M + chronic tonsillitis
 Plan:
 Diet control
 Start ceftriaxone inj
 Urine analysis
 Continuous treatment
 Consultation ENT specialist
 Transfer to ward 22

34. Progressive note
 15/08/2020 there is no new complain
 O/E: conscious alert bilateral ear yellowish
discharge
Bilateral posterior auricular lymph node enlargement
bilateral tonsilar enlargement
Temperature : 37c RR: 20bpm PR:88bpm
Assessment: sub improved
Plan: Continuous treatment & blood sugar
monitoring

35. Progressive note
 16/08/2020 the patient complains swelling and painful in the
right parotid gland aggravated by chewing and gently pressure,
no further complain good sleep & apatite
urine and stool passes normally.
 O/E the patient is conscious alert right parotid gland
enlargement and tenderness.
 V/S.
 T=36c,
 RR=20bpm,
 PR=88bpm
• Assessment: right parotid gland enlargement & tenderness
• Plan: ENT specialist consultation & blood sugar monitoring

36. Progressive note
 17/08/2020 the patient complains swelling and painful in
the right parotid gland aggravated by chewing and gently
pressure, no further complain good sleep & apatite
urine and stool passes normally.
 O/E the patient is conscious alert right parotid gland
enlargement and tenderness.
 V/S.
 T=35c,
 RR=19bpm,
 PR=100bpm
• Assessment: right parotid gland enlargement &
tenderness
• Plan: Act rapid 7unit every three hours

37. consultation
 Diabetic education
 Diet control & regular exercise
 Wear free size shoes
 Seek ENT specialist
 frequently measure the capillary blood glucose
 drink fluids to maintain Hydration
 continue taking subcutaneous insulin
 seek medical attention if dehydration, persistent
vomiting, or uncontrolled hyperglycemia develop.

38. Thank you all
Any comment or
question