DIABETES

KETOACIDOSIS
CASE PRESENTATION
Dr. NATUKUNDA FERGUSON
Dr. RIKAJU SIMON ENOCK
23rd August 2023
Demographic data
• Name: K.A
• Age: 10 years
• Sex: M
• Address: Mukono (about 25km from Mulago)
• Tribe: Ganda
• Religion: Catholic
• Admission date: 14/07/2023, 2100 hrs
• Next of kin: B.R, the mother
Presenting complaints
• Generalised body weakness x 10 days
• Weight loss x 10 days
• Increased thirst x 10 days
• Vomiting & Abdominal pain x 3 days
• Difficulty in breathing x 3 days
History of presenting complaints
• He was referred from Kayunga RRH for further management;
investigation and management.
• He was well until 10 days prior to admission when he developed
generalised body weakness. Mother reported that child was drinking
more than usual.
• The child had also lost weight (not quantified) over the period of the
illness.
HPC
• Mother noted child had increased appetite, however he started
complaining of abdominal pain 3 days prior to admission.
• 2 episodes of vomiting of non-projectile. No history of abdominal
distension or diarrhoea.
• Difficulty in breathing worsened over a 3 days period.
• No history of cough, or wheezing.
Review of systems
• CNS: Child became unconscious before referral and developed high
grade fevers, no hx of convulsions, headache or blurring of vision.
• GUT: increased frequency and child was passing copious amounts of
yellow coloured urine.
• MSS: No history joint swelling or pain
• Skin: No history of skin rash
• CVS: No history of easy fatigability, palpitations, or dizziness. No PND
or orthopnoea.
History
• Past medical hx: 1st admission, where he was managed at Kayunga
and then MNRH. HIV status unknown, no history of asthma.
• Past surgical hx: No blood transfusion, major trauma, major surgery
or burns.
• Immunisation, nutrition, growth and development as well as peri-
natal: was uneventful.
• Family and social hx: Only child, currently stays with mother.
Biological father died of T2DM.
On examination
• Child of school going age, sick looking in respiratory distress. Afebrile
to touch T- 35.5. No jaundice, had mild pallor, no cyanosis, no finger
clubbing, no oedema. Had severe dehydration, Weight: 20 kgs

• R/S : He had kussmaul breathing, Tachypnoeic at RR 52bpm, SPO2- 87

on RA. Resonant percussion note, bronchovesicular breath sounds
bilaterally. No added sounds
Physical Exam
• CNC: GCS- 7/15, E=2,V=1,M=4. PEARL, Neck was soft, Kerning’s sign is
negative, No obvious craniopathy.
• CVS: Cold extremities, weak but fast pulse, PR- 130bpm, CRT> 3s.
Normoactive precordium, HS 1 and 2 heard normal with no added
sounds. BP was not taken
• P/A: normal fullness, moving with respiration, non tender. No
palpable organs.
Summary
K.A is a 10/M referral from Kayunga RRH who presented with a 10 day
hx of GBW, weight loss and increased thirst and a 3 days hx of vomiting,
abdominal pain and difficulty in breathing with LOC. He had increased
appetite, increased urine frequency and polyuria. Biological father died
of type 2 diabetes.
O/E, Very sick, severe dehydration. He had cold extremities and CRT >
3s, tachycardia of 130bpm with a weak pulse. Had kussmaul breathing
and tachypnea of 52bpm. Spo2 was 87 on RA. GCS 7/15.
Impression
• Newly diagnosed DM type 1 with DKA
• Hypovolemic shock
• Severe malaria with cerebral malaria
• Cerebral Oedema
On admission
• Plan
- Admit
- ABCs
- Give oxygen 3L/min by nasal prongs
- RBS – Unrecordably High ( Error 8)
- Urine dipstick, leuco-15, nitrite +, protein+, PH- 5.0, blood- neg, SG-
1.030, ketones+, glucose- 30, bilirubin- neg.
- B/S- +++
Management
• IV NS 20mls/kg bolus over 20 minutes, re assess if still in shock add
10mls/kg of NS.
• Child improved with one bolus of 20mls/kg.
• Insulin was commenced as well as maintenance fluids + deficits
(10%loss).
• Deficit (10/100)x 20= 2L
• Total fluids= ½ x 2000 mls +1500 (maintenance)
• 2500- 400 (bolus given)
• 2100mls in 24 hours
Management
• Insulin 0.1 U/kg/hr= 2U/hr- actrapid (regular)
• In 6 hours, 12 u, give in 50 mls of normal saline 6 hourly – 48 hours
• IV KCL 20 mmol in 500mls of N/S
• Monitor RBS every hour for the 1st 6 hours, then 2 hourly
• Insert NG tube , keep nil per os
• Insert urinary catheter
RBS monitoring
Time RBS result
9:30pm Er8
10:30pm Er8
11:30pm Er8
12:30am Er8
1:30am 31.0 mmol
2:30am 27.3mmol
4:30am 26.2mmol
6:30am 23.6 mmol
Management
• Artesunate 50 mgs at 0, 12 and 24 hours was initiated and later oral
anti malaria medications ( coartem)
• Child was transferred to ward 11, was continuously reviewed by the
doctors.
• Child improved and was switched to subcutaneous insulin. Fixed
regimen initially on ( 1.0/kg/day)
• Mother counselled and educated about type1 diabetes mellitus.
• GCS improved to 15/15.
 Management…

• Blood sugars were monitored hourly

• Urine ketones were measured after 4 days, ++++
• Electrolytes:
Day 1 2 4 7
K 5.95 4.69 4.54 4.45
Na 133 156 133 148
Cl 94.9 99 100.5 101.2
Discharge regimen
Timing PB PL PS

NPH 6 8

Actrapid 4 3 2
Management..
• Mother got psychologically distressed
• Advice to mother to adhere to medicine and to come for review in
DM clinic after 2 weeks.
• Discharged after 15 days on ward on NPH/ actrapid insulin
THANK YOU