A 16Y old with uncontrolled sugars

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 A 16 yr old girl  who is a k/c/o DM type 1 was brought by her mother with c/0 vomitings and pain abdomen since 4 days

She was apparently alright 10 years back , one day she suddenly had fever with chills and burning sensation all over the body for which got diagnosed as DM-type 1 on routine investigations

She is on regular medication since then on INSULIN(ISOPHANE-10u+REGULAR INSULIN 10u)

After 6yrs of regular medication she missed her doses on and off for which she got admitted in the hospital with c/o vomitings ,SOB and burning micturition .necessary treatment was given and discharged 

2 years back ,Hospitalised for 1 week with similar complaints of vomitings, SOB . She got discharged with dietary counselling and insulin dosage advice

 1 year back , she got admitted with c/o fever, SOB (grade4)and acidotic breathing .ABG showed severe metabolic acidosis and ketones were positive. She was intubated and connected to mechanical ventilation . She was started on iv fluids and iv insulin algorithm 2 for management of DKA , extubated after 3 days .

Now,She had c/o vomitings and pain abdomen since 4 days

Pain in epigastric region , dull aching type, non radiating,no aggrevating and relieving factors

Vomitings since 4 days ,3-4 episodes, non projectile, non bilious,contents being food particles

She had fever ,high grade,intermittent type associated with chills and rigors

Noh/o burning micturiton, sore throat,cough, confusion, loose stools, constipation,polyuria, polydipsia

HABITS: mixed diet, normal appetite, adequate sleep,no addictions,bowel and bladder movements are regular

FAMILY HISTORY: no similar complaints

Her grand father is a k/c/o DM 

GENERAL EXAMINATION: pt is c/c/c moderately built and nourished 

No pallor, icterus, cyanosis, clubbing, koilonychia, pedal edema

VITALS: temp- afebrile 

               BP- 110/60mmhg

               PR- 104bpm

              RR- 25cpm

             Spo2-99%on room air

SYSTEMIC EXAMINATION:

P/A: shape of abdomen- scaphoid, umbilicus- inverted

        Soft, tenderness present, bowel sounds heard

CVS: s1 s2 heard, no murmurs

RS: BAE clear,no added sounds

CNS: higher mental functions are intact

         Cranial nerves: intact

          Motor system: intact

          Sensory system: intact

INVESTIGATIONS:

RBS:288mg/dl

FBS:227mg/dl

Hba1c:6.8

LDH:277

Serum amylase:24

LFT:

       Total bilirubin:1.42

        Direct bilirubin:0.17

       SGOT:12;SGPT:10;ALP:305

       Total protein:5.6;albumin:2.3;A/G:0.68

RFT:

       urea:21 creatinine:0.7  uric acid: 3.6

       Ca :9.7;phosphorus:3.9 na+:133 k+:3.4 cl-:95

TREATMENT:

1)INJ INSULIN REGULAR (14u-5u-14u)s/c TID

2)INJ ISOPHANE INSULINs/c BD(10u-10u)

3)INJ PIPTAZ 4.5g IV TID

4)INJ METRONIDAZOLE IV TID

5)INJ PAN 40mg OD

6)INJ BUSCOPAN SLOW IV

7)IV FLUIDS

8)GRBS CHARTING

PROVISIONAL DIAGNOSIS:

1)?DIABETES TYPE1 with uncontrolled sugars

2)?pyelonephritis

 3)?urinary tract infection

On day 1 and day 2 she was on regular doses of insulin on day3 due to her uncontrolled sugars(grbs-537g/dl) we started her on insulin infusion according to algorithm 1 and present grbs is 214g/dl