Presenting Complaint

Mr JA, a 57 year old Malay gentleman from Bayan Lepas who is a known diabetic, hypertensive and dyslipidemia patient, presented with shortness of breath, abdominal pain, vomiting and on and off fever associated with swelling over his back.

History of Presenting Complaint

Mr JA complained of shortness of breath which deteriorates gradually in a week. It usually worsens or happened on exertion or when he was doing strenuous activity. This was his first time and had no history of previous pulmonary infection or asthma. It was not associated with cough and did not wake him up from his sleep.

He then had generalized epigastric pain which was sharp in character. The pain started three days ago which does not relieve by taking over the counter medication (patient describes as ‘ubat angin’). The pain does not aggravates by foods, does not radiate anywhere and he rated the pain as five to six out of ten.

There was nausea and vomiting around the same time as the abdominal pain. The vomitus was about half a cup full and contained foods. There was no blood present and it usually occurred after meal. However, there was no loss of appetite and he was not sure if there is loss of weight.

The patient also complained of on and off fever since the past two weeks and swelling over his back. The fever is low grade and sometimes relieve temporarily by panadol. There was swelling over his right back first noted by his wife. The swelling was small at first presentation before it gradually enlarged. There was constant pain associated with the swelling. He applied some creams. However, it did not make it smaller or make the pain lesser. There was also pus and blood discharged when he pressed on the swelling.

Otherwise, there is no lethargy, drowsiness or coma.

Upon asking about complications of his diabetes, he denied symptoms of peripheral neuropathy such as tingling, numbness and loss of sensation. He claims his urine is normal, there is no increase in frequency, no pain or any changes in colour of the urine. Currently, there is no blurry of vision. He had cataract surgery for his left eye done five years ago.

His diet mainly consists of tosai or chapati in the morning and night (alternate) and rice with either fried chicken or grilled fish for lunch. His rice usually filled half of his plate. As for drink, he usually drinks barley with no added sugar or plain water. Sometimes when he was hungry in between the meals, he ate keropok lekor. He claimed that he usually exercise in the morning after Morning Prayer. He walks around his house for about 15-20 minutes.

Patient last admitted in November due to uncontrolled sugar level.

Past Medical History

He was diagnosed to have diabetes mellitus ten years ago and currently on two oral hyperglycaemic agents and two insulins which is novorapid and determir. He monitors his own sugar level at home. However, his sugar level rarely goes below 9.0 mmol. He has hypertension and hypercholesterolemia also since ten years ago, all diagnosed after he had stroke. Hence, he is on anti hypertensive and simstatin.

Patient also had history of cerebrovascular accident (stroke) with right sided weakness. However, there is no reasidual weakness.

Family History

His father passed away at 67 and he does not know the cause. However, his father also had diabetes mellitus and he suspect that his father also on insulin as he used injection around his abdomen. His mother passed away since he was young and he does not know why. He has eight siblings and all have diabetes mellitus, but not as high as him.

Medications

Patient claims that he is compliant to his medication and will take/continue the medication immediately in case he missed it. Currently, he is on metformin, saxagliptin, glargine and novorapid. For hypertension, he is on perindopril. He also taking simvastatin 20mg ON and one ‘blood thinner’ which he did not remember the name.

Patient was once tried T. forxiga and claims during few days of trial, his blood sugar controlled were better. However, he discontinue due to the cost.

Allergies

No allergies to food and drugs.

Social History

Patient is married and has eight childrens, all are healthy. Currently, patient lives with his son in Bayan Lepas. However, his wife left him in January this year due to his illness. Previously, patient stayed in Petaling Jaya and did his own business which he stopped after the stroke. Since then, his wife takes care of him until he was fully recovered. He is ADL independent and do his house works on his own.

He is a non smoker, non alcoholic and does not involve in high risk behavior.

Physical Examination

On general inspection, patient is alert and conscious. Not overweight, no cushingoid appearance and looks comfortable at rest. Hydration status is good. There is branula on his left dorsum.

On hands examination, there is no limited joint mobility, Dupuyten’s contracture, carpal tunnel syndrome, trigger finger, prayer’s sign and muscle wasting. Pulse rate is 90 beats per minute, regularly regular with good volume, BP is 143/77 mmHg and temperature was 37 degree Celsius. There is no hyperpigmentation and vitiligo. On face examination, there was corneal arcus, but no conjunctiva pallor. Ideally fundoscopy is used to look for cataract, lens opacity and fundus changes indicative of retinopathy, maculopathy or glaucoma. The tongue is moist and not cyanosis. There was acanthosis nigrican at the back of his neck. On the neck, there is no swelling.

There is a swelling on his right back measured 6 cm× 6 cm, circular in shape, smooth surface, edge well defined, no discharge, no punctum but the wound is wet and is erythematous. The swelling is slightly mobile. There is no increase in temperature, bruising, lipohypertrophy and erythema over skin.

The abdomen is moving with respiration. There is no needle scar noted around the umbilicus. The abdomen is soft and non tender. There is no organomegaly.

Examination of legs reveals no muscle wasting. Nails are dry and brittle, but no infection or onycholysis. There is some degree of hair loss. But, no shiny skin or any ulcer noted on the legs. No evidence of callus formation on weight bearing areas and no presence of ulcers. Peripheral pulses are present and temperature is equal on both sides. Sensation of light touch, vibration, pin prick, proprioception are intact. Plantar and ankle reflexes are normal.

Summary

Mr JA, a 57 year old Malay gentleman from Bayan Lepas who is a known diabetic, hypertensive and dyslipidemia patient, presented with shortness of breath, abdominal pain, vomiting and intermittent fever associated with carbuncle over his right upper back for the past two weeks.

On physical examination, there was corneal arcus, acanthosis nigricans and the carbuncle over his right upper back measuring about 6x6 cm.

Diagnosis

Provisional diagnosis: Diabetic ketoacidosis secondary to infection from carbuncle. Patient who is a known diabetic patient with poor glucose control in the past has typical symptoms of diabetic ketoacidosis which are shortness of breath, abdominal pain and vomitting. This can be exarcebated from infection or carbuncle on his right upper back. He also has strong family history of diabetes.

Differentials: 1) Hyperglycaemic hyperosmolar state. This needs to be the first differential in patient with suspected DKA as the presentation is more or less the same and hence, in the past it was called as hyperglycemic hyperosmolar nonketotic coma as the thing that differentiates between these two is the present of ketone in DKA. However, this needs to be confirmed by urinalysis.

Investigations

1. Tests are carried out to:a) Measure biochemical parameters to diagnose the syndrome.b) Delineate aetiologic basis or precipitating factors for ketoacidosis.c) Monitor impact of therapy.

2. Urine testing/microstix. To look for glucose, ketones and albumin levels. In this patient, the glucose is markly elevated and there is ketones in the urine. This can be due to because the body does doesn’t have enough insulin to use glucose and change to ketones. When ketones build up in the blood, they make it more acidic, hence the urine pH is low.

Test ResultSG < 1.005pH 6.5

Glucose 3+

Ketones Positive

3. HbA1c. To see patient’s controlled or average blood glucose levels over the past 3 months. The result is 11.2 which mean the sugar level is poorly control.

Test Results Reference Range LevelHbA1c (NGSP) 11.2 <6.5% High

4. Full blood count. White count is often raised in DKA and is not necessarily indicative of a bacterial infection. But, in this patient, it was accompany with carbuncle and intermittent fever. Hence, it is important to start antibiotic therapy and do blood culture and sensitivity.Results:

Test Results Range LevelWBC 13.6×10^3 uL 4.0-10.0 High. RBC 5.2×10^6 uL 4.5-5.5 NormalHGB 15.5g/dL 13.0-17.0 NormalHCT 42.4% 40.0-50.0 NormalMCV 85.4 fL 83.0-101.0 NormalMCH 29.8 pg 27.0-32.0 NormalMCHC 33.6 g/dL 31.5-34.5 NormalPLT 225×10^3 uL 150.0-400.0 Normal

5. Blood culture and sensitivity. To know if there is any specific organism infect the patient and start a targeted medication. Result is not available in the charts.

6. Renal profile. Hyperglycaemia can cause profound osmotic diuresis leading to dehydration and electrolyte loss particularly sodium and potassium. However, it is normal in this patient.Results:

Test Results Range LevelSodium 141 mmol/L 136-145 NormalPotassium 3.9 mmol/L 3.5-5.1 NormalUrea 4.3 mmol/L 2.76-8.07 NormalCreatinine 79 umol/L 62-106 NormalChloride 102 mmol/L 98-107 Normal

7. Arterial blood gas. In emergency setting, because patient complain of having shortness of breath and has several comorbidities. It is important to see if there is respiratory failure, to know the type and look for any acidosis or low bicarbonates level. In this patient, the actual bicarbonates is low which can be due to metabolic acidosis force hydrogen ions to displace potassium ion in DKA patient.Results:

Test Results Range LevelpH 7.40 7.36-7.44 NormalPaCO2 5.0 kPa 4.8-5.9 NormalPaO2 11.6 kPa 11.3-13.3 Normal

Actual bicarbonates 18.2 mmol/L 21.0-25.0 Low

8. Lipid Profile. To check the patient lipid control as the patient has hypercholesterolemia and on simvastatin. Together with diabetes, this will increase the patient risk of developing macrovascular complication, especially coronary artery disease. In this patient, the triglycerides are high. Hence, need to assess patient compliance towards medication and diet in order to establish the cause.

Test Results Range LevelCholesterol 5.1 <5.2 Normal

Triglycerides 2.19 <1.7 HighLDL 2.8 <3.3 NormalHDL 1.31 >1.00 Normal

9. ECG. In DKA, potassium level can be high at first, before it will go down when the treatment is started. Hence, patient needs to put on ECG while on treatment in the emergency setting. Other than that, to look for ECG changes such as inverted T waves, Q waves or changes in ST segment.Results: Not available in the patient’s charts.

Management

1. Correct hypovolaemia or dehydration.Average of 6-8L may need to be given for first 24 hours.Normal saline 0.9% 1 litre in one hour, then 1 litre in 2 hour, 1 litre in 4 hour, 1 litre in 6 hour, 1 litre in 8 hour. Monitor patient closely and look for any fluid overload or underhydration.

2. Insulin therapy. Continuous IV insulin infusion is the treatment of choice. Soluble insulin is diluted in 0.9% saline at a concentration of 1 U/ml.Give IV bolus 10 U soluble insulin followed by 6 U/hour by infusion pump.

3. Blood glucose should be monitored hourly. Aim for blood glucose drop of 10%.4. Potassium replacement. Administration should begin when ECG shows no evidence of

hyperkalemia, ample urine output demonstrated and plasma K<5mmol/L. Add 1 g KCL in each 0.5 litre of fluid initially. Do BUSE 4-6 hourly and monitor.

5. Bicarbonate therapy when arterial pH<6.9, severe hyperkalemia. A solution of 8.4% sodium bicarbonate in 400ml sterile water with 20 mmol/L KCL over 2 hours.

6. Replace phosphate if thise is anaemia, cardiac or respiratory dysfunction.7. Treat precipitating factors, in this case the infection from carbuncle. Give prophylactic

antibiotic and specific antibiotic when the result of blood culture is out.8. Be alert with complications of DKA and its treatment such as hypokalemia once the patient is

stable and transferred.9. Advice on patient’s dietary and lifestyle.

Referral Letter

Endocrine Department,Penang Medical College,10450, Penang. 10th May 2015

Dr A,Endocrine Specialist,Penang Hospital, Residency Road,10990, Penang.

Re: Mr JA Age: 57 IC no: 580317075408Kindly please see this patient and advice on management.

HistoryMr JA, a 57 year old Malay gentleman from Bayan Lepas who is a known diabetic, hypertensive and dyslipidemia patient, presented with shortness of breath, abdominal pain, vomiting and intermittent fever associated with carbuncle over his right upper back for the past two weeks.

Physical examinationThere was corneal arcus, acanthosis nigricans and carbuncle over his right upper back measuring about 6x6 cm, discharging of pus and blood.

Investigations1. FBC shows raised WBC.2. Renal profile is normal.3. ABG shows low bicarbonates.4. Urine microstix shows urine is acidic at pH 6.5 with positive glucose and ketones.5. HbA1c is 11.2%.6. Lipid profile shows high triglycerides level.

Management Normal saline 0.9% per hour, IV bolus 10 U soluble insulin, potassium replacement and bicarbonate therapy. Patient is adviced on his diet and lifestyle.Thank you for seeing Mr JA

Regards,(Dr. Amirul)House Officer