Case presentation:
provisional diagnosis:DKA with anterior wall MI.
History of presenting illness:
Patient presented to the casualty with c/o
vomiting, fever, since 1 day and left sided chest pain radiating to left hand, from previous night.
She was apparently normal 1 day back, she then developed low grade continuous fever which was relieved on medication, not associated with chills and rigor.
She had episode of vomiting in the morning, which was non projectile, non bilious, non foul smelling, containing food particles.
She also had abdominal pain.
Chest pain was pricking type radiating to left hand associated with heaviness, chest tightness and sweating.
Patient was said to have SOB by her son.
Past history:
She had similar complaints in the past,
In 2007 she had NSTEMI and was diagnosed to have triple vessel disease. she underwent PTCA(LCX territory) and CABG(LCX and RCA).
She had similar complaints in 2017 and was consequently treated.
She is a type 2 diabetic and hypertensive since 20yrs.she is on oral antidiabetic drugs.
Treatment history:
Vildagliptin and metformin 50/500 mg.
Telmisartan 40mg
General examination:patient was unconscious. well built, well nourished.
Vitals:
Temp:100°F
B. P:130/90mmHg
R. R:13cycles/min
P. R:83 beats/mini
Pulse was weak, irregular rhythm.
SpO2:100.
Pallor:present
Icterus, cyanosis, clubbing,pedal edema, lymphadenopathy :absent.
Investigations:
Treatment:
. Inj. HAI 1 ml (40 U) + 39 ml NS at 8 ml/hr to maintain GRBS less than 200 mg/dl
2. IVF. 1 unit NS continuous infusion at urine output + 30ml/hr
3. TAB ECOSPORIN 75 MG PO OD
4. TAB CLOPIDOGREL 75 MG PO OD
5. TAB CARDIVAS 3.125 MG PO BD
6. INJ. CLEXANE 60 MG S/C BD FOR 5 DAYS
7. TAB MONIT GTN 2.6 MG PO OD.
Day 2
Symptoms : nausea,generalised weakness,
No fever spikes,
Pain at cannula site
Bp :140/90mmhg
PR: 90bpm
RR : 18
Spo2 : 99% at room air
Pt is on insulin infusion since yesterday,
No episodes of hypoglycemia
Still continuing infusion at 1ml/hr
Input/ output: 1500/800ml
A: DKA with anterolateral wall MI(NSTEMI)
K/c/o DM and HTN
P: to break NBM and start orally
Infusion HAI 1 ml (40 U) + 39 ml NS at 8 ml/hr to maintain GRBS less than 200 mg/dl
2. IVF. 1 unit NS continuous infusion at urine output + 30ml/hr
3. TAB ECOSPORIN 75 MG PO OD
4. TAB CLOPIDOGREL 75 MG PO OD
5. TAB CARDIVAS 3.125 MG PO BD
6. INJ. CLEXANE 60 MG S/C BD FOR 5 DAYS
7. TAB MONIT GTN 2.6 MG PO OD
Day 3
Symotoms:nausea reduced ,generalised weakness
One fever spike @6pm
Temp 100.6 F
O :
Bp :140/80mmhg
PR: 82bpm
RR : 18
Spo2 : 99% at room air
insulin infusion stopped,
No episodes of hypoglycemia
Input/ output: 1100/1000 ml
A: DKA with anterolateral wall MI(NSTEMI)
K/c/o DM and HTN
P: started orally
Bridging of insulin done.. Insulin dose fixed to 10units HAI s/c tid
Plan to shift to amc
1. Inj HAI 10units sc tid
2. IVF. NS continuous infusion at urine output + 30ml/hr
3. TAB ECOSPORIN 75 MG PO OD
4. TAB CLOPIDOGREL 75 MG PO OD
5. TAB CARDIVAS 3.125 MG PO BD
6. INJ. CLEXANE 60 MG S/C BD FOR 5 DAYS
7. TAB MONIT GTN 2.6 MG PO OD
8. Inj LASIX 20MG IV BD
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