Mr. Abu is a 16 year old Malay gentlemen with no known medical illness who was referred from KK in view of high fasting glucose level (26mmol/L). He presented with fatigue for the past 1 week, polydipsia and nocturia for the past 3 weeks. The urine was always clear. He also presents with nausea and occasional vomiting for the past 3 days and has loss of appetite since 3 weeks ago. There was loss of weight within the past 1 month but he was unsure of the actual weight loss. He denies fever, cough, abdominal pain, headache, shortness of breath and numbness/tingling sensation. He has no significant family history of diabetes or hypertension. He is a non-smoker and non-alcoholic.
On admission, he was conscious and communicative but showed fatigue. His vitals were: BP-120/76, PR-88, RR-18, T-afebrile. His glucometer reading was 23mmol/L (He was infused with 1pint NS Stat at the KK before being referred)
Patient was noted to be obese, with acanthosis nigricans at neck and multiple lesions over bilateral lower limb.
CVS: DRNM
Respi: Air entry equal, no added sounds
Abdo: Soft, non-tender
Invx done on admission,
ABG noted to be metabolic acidosis(pH: 7.115, hCO3: 7.1) with respiratory alkalosis compensation(pCO2: 22.1)
Urine ketones: 150mg/dL( severe ketonuria)
Provisional Diagnosis: Diabetic Ketoacidosis in an undiagnosed Type 1 Diabetes Mellitus
Management at ED,
1. Run 2L NS bolus
2. Strict I/O Charting via CVL.
3. IV Actrapid 8U STAT
4. Start IV Actrapid infusion 8U/hr
Management in Ward
Other investigations: FBC, UFEME, FLP, HbA1C, LFT/RP, Ca/PO4/MG, daily ketones
1. IVD 2pints NS/2H with 1g KCL each pint
IVD 2pints NS/4H with 1g KCL each pint
IVD 2pints NS/8H with 1g KCL each pint
IVD 2pints NS/16H with 1g KCL each pint
2. Trace RP Urgently --> Urea: 4.2, Na: 136, K: 3.5, Creat: 137
3. Monitor vitals every hourly
4. GCS Charting- to watch out for complications such as cerebral edema
5. Strict I/O charting via CBD
6. Allow orally
7. GM every hour
8. IVI Insulin 6U/hr, to target at 6-14mmol/L
9. Once GM<14, to change to IVD Dextrose Saline
10. IV Ranitidine 50mg STAT and TDS- to prevent complications such as stress ulcers
11. S/C Heparin 7500U BD- to prevent thomboembolic events
GM monitoring:
17/3- 3pm: 15.4
4pm: 18.0
5pm: 18.0
7pm: 20.5- IVI Insulin increase to 8U/hr
8pm: 16.6- IVI Insulin decrease to 6U/hr
18/3-5am:13.9
6am:12.2
8am: 12.2
19/3-2pm:18.7
3pm:18.8
8pm: 15.1
20/3- 10.30pm: 13.3
21/3- 4am: 8.7
Progress notes
Day 2-18/3/2014
Patient is comfortable and does not complain of shortness of breath, chest pain or abdominal pain. The polydipsia has decreased. His GCS is full. His BP was 138/63, PR:66, T: afebrile, SPO2: 98% RA. Input/Output levels were good.
Invx: UFEME revealed no presence of UTI, glucose was 56, ketone 15, protein 0.25.Another RP was done and the potassium level was noted to be 3.1. Hence, Tab. Slow K 1/1 BD was added to the regime.
The plan was to complete the current fluid regimen and once complete, to give patient 4pints of Dextrose Saline/24H. The IVI Insulin 6U was to be continued until the ketosis resolves and thereafter changing it to basal bolus insulin.
Day 3-19/3/2014
Patient is comfortable and no complains of any sort. GCS full. His GM is control within 13-17mmol/L within 6H in the morning. The metabolic acidosis resolved fully (pH:7.36, HCO3:25.8, pCO2:45). Vital signs were good.
The plan was to convert to S/C Insulatard 30U STAT and ON(40U), S/C Actrapid 16U TDS, off IVI Insulin, Tab. Metformin 500mg BD. However, plan was withold as GM more than 15 in the evening. Slow K II/II BD and Mist KCL 15ml TDS i/v/o K+:2.9. IVD 3pints NS +1.5g KCL in each pint was given.
Day 4-20/3/2014
Patient is comfortable. GM<15 for the whole day. Vital signs were good. The plan was to overlap with S/C Actrapid for 1H together with IVI Insulin and after that, to off IVI Insulin. Patient was started on S/C Actrapid 16U TDS, S/C Insulatard 40U ON, Mist KCL 15ml TDS + Slow K II/II TDS and was planned for fundoscopic examination. Patient was educated by the pharmacist regarding injection administration.
Day 5- 21/3/2014
Patient is comfortable. Vital signs were good. GM level <10 for more than 24H. RP level: 0.9/135/3.2/47. K+ levels increasing after administration of Mist KCL and Slow K. Tab. Metformin 1g BD was added. Patient was allowed for discharge and was taught self-glucose monitoring. He was advised to buy a glucometer at home. He was asked to review at KK.
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