A Case of Diabetic Ketoacidosis

February 28, 2022

Welcome to my blog! I am Varshitha Kalidindi, a 2nd year medical student. This is an e-log to discuss our patient's de-identified health data after taking informed consent of the patient. It also reflects patient centered online learning portfolio.

I will be looking forward to some feedback and valuable inputs through the comments box provided below.

I have been given this case 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, diagnosis and treatment plan.

CASE:-

A 55 year old male came to the general medicine OPD with complaints of difficulty in swallowing, loss of appetite, fever and dark tarry stools all since one week. He has also been having hiccups since 4 days.

The patient was apparently asymptomatic 12 years back. He then had fever, loose stools and went to the hospital. He was diagnosed with ?acute gastroenteritis and de novo hypertension.

3 years back the patient had fever and giddiness, he went to a local hospital and was diagnosed with viral pyrexia with de novo diabetes mellitus. Since then the patient was on irregular medication. He took oral hypoglycemic agents only when he felt like it. He drinks 90-180ml of whiskey on a daily basis following which he doesn't take oral hypoglycemic agents and antihypertensives.

HISTORY OF PRESENT ILLNESS:-

Before 20 years, the patient has been drinking at least 90-180ml of whiskey on a regular basis.

Before 12 years, he was asymptomatic when he suddenly had fever and loose stools. He went to the hospital and was diagnosed with acute gastroenteritis and de novo hypertension.

3 years ago, patient had fever and giddiness and went to a local hospital. He got diagnosed with viral pyrexia and de novo diabetes mellitus. Since then, the patient had been on irregular medication. He only took medicines when he felt like he needed it and didn't take the medications after drinking (oral hypoglycemic agents and antihypertensives).

On 7/2/2022, the patient came to the OPD at KIMS with complaints of headache and a loss of appetite. He was treated on an OP basis. He felt like his attenders were not willing to spend money on him so he fought with them about it. He was then taken to a private hospital in Nalgonda, where CT and MRI brain were done. He was diagnosed with ?Neurocysticercosis/Tuberculoma. Ophthalmology opinion was taken in view of deep retro orbital pain and he was diagnosed with ocular TB. He was prescribed steroids - eyedrops of prednisolone 6 drops/day, cyclopentolate 2 drops/day, timolol 2 drops/day with T.omnicortil 20 bd and albendazole 400 bd for 7 days.

From 20/2/2022, he started feeling difficulty in swallowing(even water), loss of appetite, fever and dark tarry stools.

On 27/2/2022, he came to the OPD with these complaints. He is weak because of less intake of food and he was finally able to and eager to eat solid food on 28/2/2022. Before this he was only taking finger millet porridge everyday for at least 2 weeks.

HISTORY OF PAST ILLNESS:-

Not a known case of diabetes, hypertension, CVA, asthma, tuberculosis, epilepsy

TREATMENT HISTORY:-

Has history of diabetes since 3 years and hypertension since 12 years.

Since 3 years, he has been on oral hypoglycemic agents(glimy m) and since 12 years he has been on antihypertensives (telma h). All this medication was irregular.

PERSONAL HISTORY:-

Appetite: reduced

Diet: non vegetarian

Bowels: regular

Micturition: normal

Habits/addictions: drinks whiskey 90-180ml daily since 10 years.

FAMILY HISTORY:-

No family history of diabetes, hypertension, heart disease, stroke,cancer, tuberculosis, asthma

PHYSICAL EXAMINATION:-

General:-

No pallor, icterus, cyanosis, clubbing of fingers/toes, lymphadenopathy, oedema.

Mild dehydration present.