Quiz based approach to a patient

 

Suyash Gupta

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A quiz based approach to a patient. Let us discuss the case. We'll add questions and discussions as we go on.

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A 55 year old female, agricultural labourer by profession who was apparently alright until July of 2018 when she developed symptoms of giddiness, headache, vomiting and generalised weakness. She went to a local rural medical practitioner (RMP) who did her random blood glucose test using a glucometer which showed "hi" (many glucometer in use show "hi" when blood glucose level is more than 600mg/dl) Before that she never got her blood glucose levels checked. The RMP referred to the GP where she was given oral hypoglycemic drugs among other drugs for symptomatic management and was sent home.

She was apparently normal for a month when she again developed symptoms of vomiting and generalised weakness for which they have consulted the RMP who have referred them to the expert where she was diagnosed as Hyperosmolar Hyperglycaemic State (HHS) and was administered Inj. Insulin Mixtard (an intermediate acting insulin) and sent home after her sugar levels normalised. She was asked to take 10 units of Insulin Mixtard in the morning and 12 units in the evening.

On 13th May 2019, there was a stressful event in her home, and she happened to miss her dose of insulin followed by next day morning too. On 14th May 2019 around 11 o clock she developed symptoms of breathlessness, nausea, headache, burning micturition, abdominal discomfort, and generalised weakness. For which she was admitted in a local hospital upon consulting the RMP where she was given I.V. glucose and immediately refereed to our tertiary care hospital where the random blood sugar level came out to be 440 mg/dl

She was stabilized and up on further investigating from the treating team it has been found that she was taking Inj. Insulin Actrapid instead of the Insulin Mixtard which was the recommendation.

Based on the history that the inj which she was taking was a clear fluid where as actrapid is clear. While mixtard is milky. So, the treating team concluded that she was using wrong insulin.

Owing to her history and judging by her presenting complaints, other tests were done on which the significant findings were of pH which was 7.05, pCO2 was 6.5 and urine ketone bodies were present.

How should we proceed further?

What do you think is the diagnosis? (do keep in mind her earlier similar episodes and how she was managed).

2Rakesh Biswas and 1 other

15 comments

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• DrDeepanjan Bhattacharya

  Treat as DKA

  Switch to basal or premixed insulin

  

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  •  · 48 w
• Ekansh Rai

  Check serum electrolyte and hBa1c .

  

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  •  · 48 w
• Rakesh Biswas

  Admin

  Thanks Lucy, 

  Ekansh

  , 

  DrDeepanjan

   for those quick and useful inputs. 

  Suyash

   please tell us what happened to the patient next.

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  •  · 48 w
• Suyash Gupta

  Judging by all these factors she was diagnosed as Diabetic Keto Acidosis (DKA) and her treatment was started giving insulin infusion and supportive treatment.

  Her blood sugars levels, ketone body presence and arterial blood gases were monitored until she could be normalised.

  The patients requested an early discharge because they were not able to afford the stay in hospital because of the out of pocket expenditure for the patients (for both medications and stay in the hospital).

  The patients and the next to kin are unaware of her parents history of diabetes but her siblings (Brother and sister) were also diagnosed with diabetes.

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  How important is ketone as a marker of prognosis in an in-patient? Do you discharge a patient even if their ketones are present in urine? What levels are considered relatively safer?

  She probably took insulin actrapid, and not mixtard because of the price factor. In long run, other the number of picks and units, in what way would this be detrimental to the patient?

  What was required to counsel, when she was discharged? Could this be total insulin deficiency because of which she would be advised to take insulin life long?

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  •  · 48 w
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  • Suyash Gupta

    Avinash Kumar

     true.

    What are views of other folks on this?

    

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    •  · 47 w
• Suyash Gupta

  Considering a lot many diseases, both benign as well as critical, it is a common finding that patients have more trust towards their local doctor. Is this true? Or do they prefer some named doctor in some big metro?

  How much trust does a patient really have on their local RMP? 

  (part of our global health concern; BMJ case report)

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