1701006099 CASE PRESENTATION
LONG 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 SYSTEM -
Bilateral air entry present ,
normal vesicular breath sounds heard , no adventitious sounds heard .
CVS- S1 , S2 heard , no thrills and murmurs heard .
CNS - no abnormality detected .
Higher mental functions
conscious
oriented to person and place ,time.
memory - able to recognize their family members
Speech - normal
Cranial nerve examination -
C. N. 1 - sense of smell present
C. N. 2- Direct and indirect light reflex present
C. N. 3,4,6 - no ptosis Or nystagmus C. N. 5- corneal reflex present on both sides
C. N. 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present.
C. N. 8- able to hear
C. N. 9,10- uvula not deviated
C. N.11- sternocleidomastoid contraction present
C. N. 12- no tongue deviation
Motor system
Tone -. Upper limbs Lower limbs
Inspection - Normal Normal
Palpation - Normal Normal
Muscle bulk - Normal in both upper and lower limbs.
Muscle power -
Right Left
Biceps- 5/5 5/5
Triceps-. 5/5 5/5
Brachioradialis-. 5/5 5/5
Tibialis posterior-. 5/5 5/5
Reflexes: Right Left
Biceps- + +
Triceps- + +
Supinator- + +
Knee- ++ ++
Ankle - + +
DIAGNOSIS :: ? HYPERGLYCEMIA AND HYPERTENSIVE URGENCY (2⁰ to non compliance to medication) .
INVESTIGATIONS ::
Urinary ketone bodies - positive .
COMPLETE BLOOD COUNTS :
ECG :: 
2D ECHO :
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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SHORT CASE
A 55year old female patient who is housewife hailing from nalgonda was brought to the hospital with
CHIEF COMPLIANTS ::
* Fever since 5 days .
* Neck stiffness since 5 days.
HISTORY OF PRESENT ILLNESS ::
Patient was apparently asymptomatic 5 days back and was able to perform her regular activities without any difficulty then she experienced
FEVER
sudden onset
Continuous
Associated with chills and rigor
Associated with generalised body pains and headache .
Associated with 1 episode of vomiting which is non projectile, non bilious , food particles as content and non foul smelling. Not associated with abdominal pain and loose stools.
Relieved on medication.
NECK STIFFNESS
Sudden onset
Associated with decreased range of movements at neck
No H/O trauma
Not relieved on rest and painkillers.
No H/O Burning micturition.
PAST HISTORY ::
No similar compliants in the past.
Not a known case of hypertension , Tuberculosis, epilepsy, asthma and CAD.
H/O CVA with compliants of bilateral upper & lower limb paralysis 7 years back for which she was treated and recovered in 1month .
Surgical H/O - Hysterectomy 25years back.
PERSONAL HISTORY ::
Diet - Mixed
Appetite - reduced
Sleep - adequate
bladder - regular
Bowel movements - constipation since 3 days
No addictions and no known allergies.
FAMILY HISTORY ::
Not significant.
GENERAL EXAMINATION ::
Patient is conscious, coherent, and cooperative.
Moderately built and nourished.
Well oriented to time, place and person.
Patient was examined in supine position in a well lighted room after taking consent and explaining the procedure.
PALLOR - absent
ICTERUS - absent
CLUBBING - absent
CYANOSIS - absent
LYMPHADENOPATHY - absent
EDEMA - absent
VITALS ::
Temperature - 99⁰F
Pulse rate - 98 beats per minute , normal volume , character and normal vessel wall , no radioradial and radiofemoral
delay .
Respiratory rate - 20cycles per minute
Blood pressure - 110/70 mmHg in both arms.
O2 sat. - 96% at room air.
SYSTEMIC EXAMINATION::
CNS EXAMINATION:
Higher mental functions : NORMAL
Cranial nerve examination :
All cranial nerves functions are intact.
Cerebellar examination : No abnormality detected
Sensory system examination - Normal .
Motor system -
Muscle bulk - normal in both upper and lower limbs.
Tone - normal in both upper and lower limbs.
Power - normal in both upper and lower limbs.
nuchal muscle stiffness present , slight tenderness over the neck.
Reflexes -
Biceps - present on both sides
Triceps - present on both sides
Supinator - present
Knee - present on both sides
Ankle - present on both sides
Plantar reflex - normal bilaterally.
Meningeal signs:
neck stifness - present
Kerning's sign - positive
Brudzinski's sign - positive .
Other system examination :
Cardiovascular system -
S1 , S2 heard , no murmurs.
Respiratory system examination -
Bilateral air entry present
Normal vesicular breath sounds
No advetitious sounds.
Per abdomen examination -
Soft and non tender
No organomegaly .
DIAGNOSIS:
? Viral infection with 2⁰ viral meningoencephalitis under evaluation.
INVESTIGATIONS ::
HEMOGRAM ::
LIVER FUNCTION TEST:
RENAL FUNCTION TEST:
ARTERIAL BLOOD GAS ANALYSIS:
COMPLETE URINE EXAMINATION:
ECG :
MRI of BRAIN:
Findings : few areas of leptomeningeal enhancement in the sulcal areas of parietal and occipital region.
X RAY - SKULL& CERVICAL SPINE :
PROVISIONAL DIAGNOSIS :
Dengue fever with meningoencephalitis.
Denovo type 2 Diabetes mellitus.
TREATMENT ::
Inj. CEFTRIAXONE 2 gm/ BD
Inj.DEXAMETHASONE 6mg/iv/tid
Inj . Vancomycin 1gm/iv
Inj. Paracetomol 1gm/iv
Tab . Paracetomol 650 mg
Tab. Ecospirin 75 mg /po/od
Tab. Atorvastatin 10 mg /po/od
Syp. Cremaffin plus 30ml/po
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