50Y/M WITH DKA SECONDARY TO SEPSIS WITH AKI

 CASE:

A 50 year old male patient farmer by occupation, presented to causality with chief complaints of fever since 2 days, delayed response to verbal commands since morning and involuntary movements of left upper limb for 10-15 mins in the morning.

History of presenting illness:

Patient was apparently asymptomatic 10 days back when he had 1 episode of high grade fever, with reduced appetite, not associated with vomiting, loose stools, cough, headache, treated outside with IV fluids, ceftriaxone (2 doses) for 1 day. The patient continued to have reduced appetite, consumed only milk and liquids and continued to take OHA everyday. No reoccurrence of fever. 

This morning the patient had an episode of left upper limb involuntary movements, large amplitude, low frequency? Chorea for 10-15 mins. When his GRBS was checked by RMP, found to be high and insulin given.

Patient was brought to our hospital in drowsy but arousable with painful stimuli state.

Past history:

K/C/O DM-II since 10 years on OHA

H/O RTA 4 years back, underwent nephrectomy. 

H/O left sided tingling and numbness 6 months back, with no weakness and started on Tab. Clopidogrel 75mg/OD + Atorvas 20mg

Personal history:

Consumes mixed diet

Reduced appetite

Bowels regular

Micturition normal

Addictions: none

Family history:

Not significant

General examination:

Patient is drowsy but arousable with painful stimuli

Vitals:

Temp: afebrile

PR: 52 bpm

BP: 140/90 mmHg

RR: 31 cpm

Systemic examination:

CVS: s1 s2 heard

RS: BAE+ NVBS+

P/A: Soft, non tender, no organomegaly

CNS: NFND

Provisional diagnosis:

?DKA

With H/O nephrectomy 4 years back post rta

With K/C/O DM-II since 10 years
























ECG: 



Chest X-ray:


Investigations:






Treatment given:

Day-1

  1. NBM till further orders
  2. Foley’s catheterisation 
  3. Head end elevation 30 degrees
  4. Inj. HAI 6IU/IV/STAT
  5. Inj. HAI 40IU in 39ml NS @ 6ml/hr
  6. Inj. Sodium bicarbonate 100mEq/IV/STAT
  7. IVF-0.9% NaCl (1-3hrs-10-20ml/kg/hr). Consider 0.9% NaCl for 1st 4 hrs
  8. GRBS hourly
  9. If GRBS<250mg/dl change fluids to IVF- fusodex (5% dextrose+0.45% NS) @ 150-250 ml/hr
  10. Next 6 hrs and 12 hrs- 0.45% NS @250-500ml/hr
  11. Serum K to be monitored 4th hourly
  12. ABG 6th hourly
  13. Strict I/O charting
  14. BP/PR/Temp charting hourly
  15. Inj. Piptaz 405gm/IV/STAT f/b inj. Piptaz 2025gm/IV/STAT
  16. Syrup ascoril/PO/TID


Day-2

Delirium secondary to uremic encephalopathy or metabolic (hyperglycaemia)

Diagnosis: DKA secondary to sepsis with AKS (resolving)

K/C/O type II DM 

H/O nephrectomy 6 years back post RTA

? CVA

GRBS: 150 mg/dl

I/O: 2000/800 ml in last 24 hrs


1. Inj. PIPTAZ 2.25 gm IV/TID

2. IVF- NS@ 100ml/hr continuous infusion

3. Strict I/O charting

4. BP/PR/Temp/ SpO2 charting

5. Inj. PAN 40 mg IV/OD

6. Inj. OPTINEURON 1 amp in 100 ml NS IV/OD

7. Inj. HAI 1ml+ 39ml NS IV infusion @ 3 ml/hr

8. Inj. KCl 2 amp in 0.45 % NS@ 100 ml/hr

9. GRBS monitoring 

10. Inj. 5% DEXTROSE @ 75 ml/hr if GRBS< 150mg/dl





Day-3

Sensorium improved


Subjectively- drowsy but arousable

No irritability


Objectively- conscious but drowsy

Febrile- *103* F

SPO2-91% on RA

BP- 110/70

PR- 104bpm (Relative bradycardia)

CVS-S1S2

RESP- End inspiratory crepitations B\L basal areas (R>L)

CNS- no focal deficit

No meningeal signs

P/A - no tenderness


Assessment- To rule out pulmonary pathology.


Plan- Serial GRBS monitoring and titration of insulin

Urinary electrolytes to rule out ATN.

Check on Urea and creatinine level.

GRBS: 190mg/dl

1. IVF 0.45% NS @ 100ml/hr continuous 

2. Inj. HAI 1ml (40 units) + 39 ml NS IV infusion @ 3ml/hr

3. Inj. 5% DEXTROSE if GRBS< 150mg/dl

4. Inj. PAn 40 mg IV/OD

5. Inj. OPTINEURON 1 amp in 1oo ml NS IV/OD

6. Inj. KCl 2 amp in 0.45 % NS@ 100 ml/hr

7. GRBS monitoring 

8. Strict I/O charting

9. BP/PR/Temp/ SpO2 charting

10. Tab. RIBOFLAVIN 10mg PO/BD

11. Inj. LEVOFLOXACIN 750mg IV/BD

12. Inj. METROGYL 100ml IV/TID

13. Tab. DOLO 650 mg TID.


ENT referral taken for hyperpigmented lesions on the tongue and hard palate and scrapings sent for culture/sensitivity and microscopy.





Day-4:
Subjectively: patient is responsive to verbal commands well. No irritability

Objectively: conscious and cooperative
Febrile: *101* F
SpO2: 90% on RA
BP: 100/60 mm Hg
PR: 99 bpm
CVS: S1S2
RS: 
CNS: NFND. No meningeal signs
P/A: no tenderness

Assessment: confirmed mucormycosis on oral scrapings C/S and microscopy. Report from today’s repeat examination found hyphae to be aseptate and belong to zygomycetes. 


Diagnosis: 
DKA secondary to sepsis with AKI (resolving) 
Mucormycosis
K/C/O type II DM with ? CVA

Plan - 
serial monitoring of GRBS and titration of insulin
Treatment for mucormycosis with lysosomal amphotericin-b

1. IVF 0.45% NS @ 100ml/hr continuous 

2. Inj. HAI 1ml (40 units) + 39 ml NS IV infusion @ 3ml/hr

3. Inj. 5% DEXTROSE if GRBS 150-200mg/dl

4. Inj. PAN 40 mg IV/OD

5. Inj. OPTINEURON 1 amp in 1oo ml NS IV/OD

6. Inj. KCl 2 amp in 0.45 % NS@ 100 ml/hr

7. GRBS monitoring 

8. Strict I/O charting

9. BP/PR/Temp/ SpO2 charting

10. Tab. RIBOFLAVIN 10mg PO/BD

11. Inj. LEVOFLOXACIN 750mg IV/BD

12. Inj. METROGYL 100ml IV/TID

13. Tab. DOLO 650 mg TID.









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