Case of 42 year old female with diabetic ketoacidosis associated with left foot cellulitis

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   I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a  diagnosis and treatment plan.

CASE PRESENTATION:

A 42 year old female came to the OPD with

CHIEF COMPLAINTS :

Fever with chills since 6 days 

Vomitings 5 days back

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 6 days back then she developed high grade fever with chills. It was relieved on taking medication. 

It was associated with headache and generalised body pains. 

She had about 10 episodes of vomitings on the day of admission which was bilious, non-projectile. 

Patient also complained of blackish discolouration of left foot. Initially she developed a small bleb on the plantar surface of the left foot. Home remedies were practiced on the foot due to which the bleb got infected in the due course. 

She under went colonoscopy 3 months ago and was diagnosed with internal hemorrhoids and prescribed with medication for a month

PAST HISTORY:

K/C/O Diabetes Mellitus since 7 years

She has been on oral hypoglycemics for 6 years and started taking Inj. INSULIN since 1 year ( 20 units morning and 15 units at night) 

K/C/O Internal hemorrhoids

Not a K/C/O HTN, CVD, TB, asthma

FAMILY HISTORY: Insignificant

PERSONAL HISTORY:

Diet: Mixed

Appetite: Normal

Sleep: Adequate

Bowel and bladder habits : Regular

Addictions : No

GENERAL EXAMINATION:

Patient was conscious, coherent and cooperative. 

Patient was examined in a well-lit room after taking informed consent

No pallor, icterus, cyanosis, clubbing, lymphadenopathy. 

Oedema - Oedema of Left foot was present

VITALS:

Temp: 104°F

RR: 22cpm

BP: 110/70 mmHg

SpO2: 96% on RA

GRBS: 356 mg%

SYSTEMIC EXAMINATION:

CVS: S1S2 heard, no murmurs

RS: BAE + , NVBS heard

PER ABDOMEN: soft, non tender

Liver and spleen not palpable

No guarding and rigidity

CNS: NAD

INVESTIGATIONS:

HEMOGRAM: 

                              15/1               18/1               20/1

Hb (gm/dl)            8.5                 9.5                 8.8

TLC                     15,700          18,600            16,900

Neutrophils         83                   77                  72

Lymphocytes       8                     14                  18

PCV                      26.3                29.2                27.1

MCV                    58.3                 59.7                60.2

MCH                   19.1                 32.4                19.6

Platelets            2.69L               2.77L              3.03L

RFT:

Urea: 22

Creatinine: 0.7

Uric Acid: 2.7

Na+ : 40

K+ : 3.4

Cl: 98

LFT:

TB: 2.19

DB: 0.38

AST: 10

ALT: 08

ALP: 161

TP: 5.1

A/G: 1.19

CUE:

Alb: 2+

Sugars: 3+

Pus cells: 4-5

HbA1C: 7.5%

FBS: 214

PLBS: 229

ECG :

PROVISIONAL DIAGNOSIS :

Diabetic ketoacidosis with left lower limb cellulitis

TREATMENT:

IVF NS 3L FOR 3HRS @150ML/HR.

INJ PAN 40MG IV/OD.

IVF 5%DEXTROSE 50-100ML/HR.

INJ OPTINEURON 1AMP IN 100ML NS/IV/OD OVER 30MINUTES.

INJ HAI 0.1IU/IV/KG WEIGHT IV BOLUS.

INJ NEOMOL 1g/IV/SOS.

INJ ZOFER 4MG/IV/TID.

STRICT BP,PR,TEMP MONITORING.

GRBS MONITORING HOURLY

STRICT LOWER LIMB ELEVATION