1. Name: xyz Age: 11yrs. Sex: female Weight: 19 kg Unit: pediatric-II

2. Reason for admission: Referred here due to high blood sugar. c/o fever x 5days sudden in onset , mild to moderate associated with chills no rigors. c/o excess urination & intake of water x 2days c/o excess thirst & eating of food x 2 days

3. PMHX: NS Allergy: NKA

4. DIABETIC KETOACIDOSIS

5. BP: 86/60 mmHg PULSE:92 bpm o/e: Febrile T=100 0F RR = 26 bpm conscious , pallor + signs & symptoms of dehydration CVS: S 1 S 2 + R/S : B/L NVBS + P/A: soft , non tender , no organomegaly CBG: 459 mg/dl 7:30 pm- 312mg/dl 8:30 pm- 192mg/dl

6. CNS Lethargic , Adv: ophthalmology opinion Report: Fundus normal- both eyes

7. HAEMATOLOGY: BIOCHEMISTRY: Hb: 13.2 g % WBC: 9, 300cells/cumm RBS:454mg/dl(70-150) DLC: N -51% Urea:40mg/dl E -1% SCr:1.3 mg/dl B -0% L -49% ELECTROLYTES: M -0% Na- 133 mmol/L (135-147) PLT -4.39lakhs/cumm K 4.9 mmol/L (3.5- 5) Cl- 102mmol/L (95-105) Ca- 10.8mg/dl (8.8-10.8)

8. MICROBIOLOGY Urine ketones +++ Albumin : nil Sugar : 2% Pus cells: 2-3 Epithelial cells: 1-2

9. Rx: IVF NS bolus @ 20 ml/ kg over 1 hr. 400ml followed by NS @ 117 ml/ hr Actrapid insulin iv 5 units qid

10. TIME THERAPY 1ST HOUR 10-20ml/kg iv bolus 0.9% NaCl or RL.insulin drip at 0.05 to 0.1/kg/hr 20 ml/kg x 20 kg= 400ml iv bolus 2nd HOUR until DKA resolution 0.45% Saline plus continue insulin drip 5% glucose if blood sugar less than 250mg/dl

11. Note that the initial iv bolus is considered part of the total fluid allowed in the first 24 hrs and is subtracted before calculating the iv rate. Maintenance (24 hrs)= 100 ml/kg(for the first 10 kg)+ 50 ml/kg (for the 2nd 10 kg) + 25 ml/kg(for all remaining kg) i.e. 1000+(50 x 9)= 1450ml

12. i.v rate= 85 ml/kg + maintenance bolus 23 hrs (85 x 19 )+ 1450 400 23 =117 ml NS @ 117 ml/ hr for 23 hrs

13. BP: 108/60mmHg PULSE: 92bpm No fresh complaints o/e : afebrile , conscious, alert , oriented hydration adequate urine: ketones -ve P/A : soft , CNS : NAD Adv: Stop insulin infusion after given SC with monitoring

14. IVF- stopped Inj Actrapid 10 units SC qid CBG 8:30 am 106 mg/ dl 9:30 am -186 mg/dl

15. BP: 100/60 mmHg PULSE:96 bpm o/e : No fever conscious , oriented & alert hydration : adequate urine ketones: negative Adv: Dietic advice, CBG monitoring Continue insulin at 10 units SC qid CBG : 3:00 am- 379 mg/ dl 9:30 am 469 mg.dl 10 pm- high

16. BP: 100/68mmHg PULSE:90 bpm o/e : afebrile urine sugar +++ ketones -ve Adv : Inj.Actrapid 12 units qid proper diet management CBG: 4 am- 378 mg/dl 4 pm- 337 mg / dl 10 pm- 229 mg/dl

17. BP: 100/60 mmHg PULSE:92 bpm Hydration adequate Adv: Diet counselling 10 units qid with CBG monitoring CBG: 5 :30 am -278mg/dl 12 pm- 396 mg/dl 6 pm 425 mg/dl

18. No fresh complaints No dehydration Adv: Stop Actrapid Start Mixtard insulin 25- 0-15 from tomorrow morning: 15-0-15

19. DAY 6 DAY 7 CBG 12 am- 441 mg/dl 6 am- 159mg/dl 12pm 341mg/dl 6pm- 395 mg/dl CBG 1 am- 325mg/dl 7am-235mg/dl 10am-202 mg/dl 6pm-270 mg/dl

20. Adv: 15-0-10 units Repeat CBG at midnight & afternoon CBG 6 am-74 mg/dl 9:30 am-266mg/dl 2:30pm 225mg/dl

21. Pulse: 100 bpm o/e : no fever no dehydration Adv: 25-0-15 units To give midnight snack CBG 1 am-365mg/dl 6 am- 186mg/dl

22. Pulse:102 bpm o/e : afebrile no signs & symptoms of respiratory distress Adv: continue 25-0-15 units CBG 12 MN- 358mg/dl 6 am- 93 mg/dl

23. Pulse : 88 bpm o/e: RS clear CNS: NAD P/A : soft ,nontender CBG 1am-267 mg/dl 7am-389mg/dl 1pm-328mg/dl 7pm-402 mg/dl

24. Adv: Discharge on insulin 25-0-15 units Follow up regularly CBG 12MN- 315mg/dl 6am- 102 mg/dl

25. Drug D R F 8/2 9/2 10/2 11/2 12/2 13/2 14/2 IVF NS bolus 400m l iv - - - - - - Foll by NS 117 ml/hr iv sos sos sos sos sos Actra pid insuli n SC QID 10U 10U 12U 10U 10U - Parac etam ol 170 mg supp sos sos sos sos sos sos Mixta rd SC BD - - - - - - 25-0 -15

26. Drug D R F 15/2 16/2 17/2 18/2 IVF NS bolus - - - - - - - Foll by NS - - - - - - - Actrapi d insulin SC - - - - Paracet amol 170 mg supp sos sos sos sos sos Mixtar d SC BD 15-0- 10 25-0- 15 25-0- 15 25-0- 15

27. Subjective fever polyuria polydipsia & polyphagia Objective Urine ketones +++ Urine sugar : 2% Elevated RBS: 454mg/dl (70-150)

28. DIABETIC KETOACIDOSIS

29. Fluid & electrolyte balance Correction of hyperglycemia To prevent hypokalemia & cerebral edema

30. IV Fluids Insulin preparations: Rapid acting- Lispro , Aspart , Glulisine Intermediate acting NPH Long acting Glargine , Detemir

31. Sign & symptoms of dehydration was reduced by Day 2 Urine ketones were absent by Day 2

32. Blood Glucose levels Body weight Electrolytes Urine ketone & urine sugar Symptoms of hyperglycemia Symptoms of cerebral edema Diet habits

33. Bicarbonate level not monitored

34. ABOUT THE DISEASE sign & symptoms complications ABOUT THE MEDICATION purpose & dose importance of medication adherence possible adverse effects

35. ABOUT LIFESTYLE MODIFICATION Diet Exercise