1701006079 CASE PRESENTATION
LONG CASE
A 30 year old female patient, who is a housewife and resident of Nalgonda came to OPD with chief complaints of:-
Puffiness in face and pedal edema since 2 days.
Shortness of Breath since 2 days.
Abdominal pain since 2 days.
History of presenting illness:-
Patient was apparently asymptomatic 7 months ago, then she developed facial puffiness and B/L leg swelling which was pitting in nature.
Shortness of breath which is insidious in onset, gradually progressed to grade 4, not affected with change in position, no aggravating and relieving factors.
Abdominal pain: epigastric pain since 7 days which started suddenly and burning type of pain.
Past history:
She is a known case of hypertension since 12 years .
Personal history:
Diet - mixed
Appetite - Decreased
Sleep - Inadequate
Bladder - Decreased urine output
Bowel movements - normal
No addictions.
Family history:
Patient mother is a hypertensive .
General examination:
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Edema - absent
Vitals:
Temperature - Afebrile
Pulse - 110 bpm
Blood pressure - 150/90mmHg
Respiratory rate - 36 cpm
Systemic examination:
Respiratory system:
Patient examined in a sitting position.
INSPECTION:-
oral cavity- Normal
Nose- normal
Pharynx-normal
Respiratory movements : bilaterally symmetrical
Trachea - central in position .
Nipples are in the 4th Intercoastal space(ICS)
Apex impulse visible in 5th intercostal space
PALPATION:-
All inspiratory findings are confirmed
Trachea - central in position
Apical impulse @ left 5th Intercoastal space.
Respiratory movements - Bilaterally(B/L) symmetrical .
Tactile and vocal fremitus - reduced on both sides in infra axillary and infra scapular region.
PERCUSSION-
Dull in both sides
AUSCULTATION-
Decreased on both sides.
bronchial sounds - heard .
Cardiovascular system:
JVP -raised
Visible pulsations- Absent
Apical impulse - shifted downward and laterally
Thrills -absent
S1, S2 - heart sounds muffled
Pericardial rub -present
Abdomen examination:
INSPECTION:-
Shape - Distended
Umbilicus - normal
Movements - normal
Visible pulsations - absent
Surface of the abdomen - normal
PALPATION:-
Liver - Not palpable
PERCUSSION:- Dull note is evident.
AUSCULTATION:- Bowel sounds are heard .
INVESTIGATONS:
USG:
Radiographic findings:
ECG:
PROVISIONAL DIAGNOSIS:
Chronic Kidney Disease on Maintenence Hemodialysis
Management:
INJ. METROGYL @ 100ml/IV/TID
INJ. MONOCEF @ 1gm/IV/BD
INJ PAN 40mg/IV/OD
INJ. ZOFER. 4mg/iv/SOS
TAB. LASIX. 40mg/PO/BD
TAB. NICORANDIL 20mg/PO/TID
INJ. BUSOCOPAN /IV/stat
Add on DRUGS :
TAB. OROFENPO@ BD
TAB. NODOSIS 500mg/PO/TID
INJ.EPO 4000 ml/ weekly
TAB. SHELLCAL/PO/BD
DIALYSIS (HD)
INJ.KCL 2AMP IN 500 ml NS over 5min.
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SHORT CASE
This is a case of a 75year old woman who is a housewife , resident of miryalaguda was brought to the casuality with
CHIEF COMPLIANTS ::
*Giddiness since 1day
* vomitings since 1day .
HISTORY OF PRESENT ILLNESS ::
Patient was apparently asymptomatic 6years back and was able to perform her regular activities without any difficulty then she experienced headache and generalised weakness for which she consulted a local medical practitioner and was diagnosed with TYPE 2 DIABETES MELLITUS and HYPERTENSION. She was prescribed with medicines ( oral hypoglycemic drugs and antihypertensive drugs) and was on regular medication.
4 days back she went to her relatives house and has a H/O no intake of antihypertensives and oral hypoglycemic drugs due to which she developed vomitings and giddiness.
VOMITINGS -
* Sudden onset
* Non bilious , non projectile , non foul smelling.
* Food particles as content .
* Not associated with fever , pain abdomen and loose stools.
She was taken to the local hospital and was found to have General random blood sugar ( GRBS) 394mg/dl.
And also urinary ketone bodies were positive .
No H/O chest pain , palpitations , syncopal attacks.
No H/O shortness of breath , burning micturition .
PAST HISTORY :
No similar compliants in the past.
Not a known case of tuberculosis , Coronary artery disease, epilepsy , asthma .
Surgical history : H/O cataract surgery 3 back in right eye and 2 yrs back in left eye .
PERSONAL HISTORY:
Mixed diet
Appetite normal
Sleep adequate
Bowel and bladder regular
Addictions : chutta smoking for 10years , 3 chutta per day and stopped 5 years back.
Intake of alcohol and toddy on social gatherings.
FAMILY HISTORY ::
Not significant.
No H/O Tuberculosis, epilepsy, asthma .
GENERAL EXAMINATION ::
Patient is conscious, coherent and cooperative ,
well oriented to time, place , person.
Moderately built and nourished.
Patient was examined in supine position in a well lighted room after taking consent.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Edema - absent
VITALS :
Temperature - afebrile
Pulse rate - 90beats per minute , regular volume and character , no radio radial and radiofemoral delay.
Respiratory rate - 20cycles per minute
Blood pressure - 230/110mmHg at the time of presentation.
On 10 /06/2022 - 150/100mmHg .
GRBS - 394mg/dl ( at presentation)
On 10/06/22 - 226mg/dl .
SYSTEMIC EXAMINATION ::
GIT
INSPECTION ::
Abdomen - distended
Umbilicus - transverse slit like
Movements - all quadrants are equally moving with respiration
No scars and sinuses
No visible peristalsis
No engorged veins.
PALPATION::
No local rise in temperature and no tenderness in all quadrants
LIVER: no hepatomegly
SPLEEN- not enlarged
KIDNEYS - bimanual palpable kidneys
PERCUSSION ::
no shifting dullness
AUSCULTATION ::
Bowel sounds are heard and are normal
No bruit.
Other system examination ::
RESPIRATORY- bilateral air entry is present , normal vesicular breath sounds heard.
CVS- s1 s2 heard .
CNS - no abnormality detected .
DIAGNOSIS :: ? HYPERGLYCEMIA AND HYPERTENSIVE URGENCY (2⁰ to non compliance to medication) .
INVESTIGATIONS ::
Urinary ketone bodies - positive .
COMPLETE BLOOD COUNTS :
ECG :: 
PROVISIONAL DIAGNOSIS ::
DIABETIC KETOSIS WITH HYPERTENSIVE URGENCY.
TREATMENT ::
1. I.v fluids (normal saline,ringer lactate) at 100ml/hr.
2. Inj. Human actrapid insulin i.v. infusion at 6ml/hr.
3. Inj.Zofer 4mg i.v. /TID
4. Optineuron 1 ampule in 1000ml NS i.v. OD
5. Nicardia 20mg PO stat.
6. Hourly GRBS , B.P. , vitals monitoring.
7 . Strict I/O charting.
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