49/M with vomitings

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 Case :

A 49 year old man, resident of AP Lingotam, an auto driver by occupation has come with complaints of vomiting (On 18th of July, 2022).

History of present illness:

The patient was apparently asymptomatic 10 years ago, then he went to a hospital for fever and generalised weakness and was diagnosed with diabetes and has been prescribed oral hypoglycaemic agents (Metformin). 

6 years ago, he had a history of vomiting and had low potassium levels for which he was treated.

15 days ago, he had headache with blackouts and also had vomiting (2-3episodes) and went to a local hospital. He was referred to a higher centre (NIMS) and he was diagnosed with Acute Ischaemic Stroke.

On 18/7/22 at around 3 AM he started to have vomitings, 8-9 episodes, non bilious, non projectile, with food particles in the vomit. He went to a local hospital and found his sugar levels were spiked and was referred to our hospital. 

Past history:

H/o Diabetes mellitus since 10 years and is on regular medication (Metformin 500mg)

No H/o CAD, Tuberculosis, epilepsy, asthma, hypertension 

Family history: 

No similar complaints 

Personal history:

Appetite: Normal

Diet: Mixed

Bowel and bladder movements: Regular

Sleep: Adequate 

Addictions: He consumes alcohol (90ml) occasionally

                   and smokes beedi (1 pack daily)

Daily routine: 

He waked up at 6 AM in the morning and goes to work at around 8 AM. He has his breakfast at 10 AM. He usually has his lunch at 1 PM and continues with his work and then comes home at around 7 PM. Has his dinner by 9 PM and sleeps at 10 PM

General Examination:

Patient is conscious, coherent and cooperative

He is moderately built and nourished.

No Pallor, Icterus, Cyanosis, Clubbing, Generalised lymphadenopathy, B/l pedal edema.

Vitals:

Temperature: Afebrile

Pulse rate: 100bpm

Blood pressure:160/90 mm of Hg 

Respiratory rate:18cpm

GRBS: 416mg/dl on 28/07/22

           133mg/dl on 20/07/22

Systemic examination:

Respiratory system: B/l air entry +, normal vesicular breath sounds heard 

Cardiovascular system: S1, S2 heart sounds heard, no murmurs heard

Central nervous system: 

He is conscious 

Speech: normal 

Tone:

      upper limbs : normal 

      Lower limbs : normal 

Reflexes:

Deep tendon reflexes:

Right side:                            Left side:

Biceps:  +                                  +

Triceps:  +                                 +

Supinator:+                               +

Knee:     +                                  +

Ankle:    +                                 +

Plantar:  +                                 +

Per abdomen: flat, no distension 

Soft, non tender 

Liver: not enlarged 

Spleen: non palpable

Provisional diagnosis:

Diabetic ketoacidosis 

Investigations:

Hb: 12.3gm/dl

RBC:6.05

TLC:11,300

Platelet count:3.24lakh

ABG:

Urine examination:

Sugars: ++++

Ketones:+

ECG:

Treatment:

IV fluids NS@125ml/hr

Inj.NPH SC BD

Inj.HAI SC TID

Inj.OPTINEURON 1amp in 100ml NS IV OD

Inj.ZOFER 4mg IV

Inj.NEOMOL 1gm IV

Tab.ECOSPRIN 150mg OD

Tab.CLOPITAB 75mg OD

Tab.ATORVASTATIN 40mg OD

Tab.TELMA 40mg OD