LONG CASE
75year old female who is a housewife , resident of miryalaguda was brought to the casuality with
CHIEF COMPLIANTS
Giddiness since 1day
Vomiting 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 Agents 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 in 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 - 90 beats per minute.
Respiratory rate - 20 cycles per minute
Blood pressure - 230/110mmHg at the time of presentation.
On 10 /06/2022
Blood pressure - 150/100mmHg.
GRBS - 394mg/dl ( at presentation)
On 10/06/22 - 226mg/dl .
11/06/2022
Blood pressure - 180/100 mm Hg
Pulse rate - 72 beats per minute
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:
Inspection:
No tracheal deviation
Chest bilaterally symmetrical
Type of respiration: thoraco abdominal.
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.
Palpation:
No tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Tenderness over chestwall- absent.
Vocal fremitus- normal on both sides.
Percussion:
Supraclavicular
Infraclavicular.
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapular
Interscapular
Right side and left side- resonant in above areas.
Auscultation:
Normal Vesicular breath sounds
Bilateral Airway entry - present.
Cardiovascular system:
Inspection : no visible pulsation , no visible apex beat , no visible scars.
Palpation: all pulses felt , apex beat felt.
Percussion: heart borders normal.
Auscultation:
Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.
Central Nervous system:
Higher motor functions- Normal
Speech: Normal
Cranial nerve functions - Intact.
Sensory system- sensitive to pain, touch , vibration and temperature.
Motor system Right. Left
Power- UL 5/5 5/5
LL 5/5 5/5
Neck Normal
Trunk muscles Normal
Tone- UL Normal Normal
LL Normal Normal
Reflexes-
Superficial reflexes - Intact
Plantar flexion flexion
Deep tendon reflexes -
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
Gait- Normal
Cerebellar system - intact
DIAGNOSIS :
HYPERGLYCEMIA AND HYPERTENSIVE URGENCY (2⁰ to non compliance to medication) .
INVESTIGATIONS :
Urinary ketone bodies - positive .
ECG :
2D ECHO Report :
PROVISIONAL DIAGNOSIS :
DIABETIC KETOSIS WITH
HYPERTENSIVE URGENCY.
TREATMENT ::
1. I.V fluids (normal saline,ringer lactate) at 100ml/hr.
2. Inj. Human act rapid 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.
----------------------------------------------------------------------------------------------------------------
SHORT CASE
Chief complaints:
Shortness of breath Since 2 days
Bilateral pedal edema since 2 days
Decreased urine output since 2 days
History of presenting illness:
Patient was apparently asymptomatic 6 years back and then she developed bilateral pedal edema for which she visited hospital and diagnosed with hypertension and renal failure
And was on conservative management. Now she presented with Shortness of breath since 2 days which is of grade 4 (According to MMRC grading) and not associated with chest pain and sweating, nausea and vomiting.
Bilateral pedal edema since two days which is of pitting type and
Decreased urinary output since two days , no burning micturition ,there is increased hesitancy and frequency.
Past history:
Known case of hypertension and CKD since 6 years.
Denovo type 2 diabetes mellitus ( diagnosed after coming to our hospital- GRBS 418mg%)
Not a known case of Asthma, Tuberculosis, epilepsy,CAD.
No significant past surgical history.
No blood transfusions.
Personal history:
Diet mixed
Appetite normal
Sleep adequate
Bowel regular
Bladder decreased urinary output
No known drug or food allergies
No addictions
Family history:
No significant family history
General examination:
Patient is conscious, coherent and cooperative well oriented to time ,place and person
Well built and well nourished
Pallor present
Icterus absent
Clubbing absent
Cyanosis absent
Generalised lymphadenopathy absent
Pedal Edema present
Pedal edema
Vitals
Pulse rate -106bpm
Blood pressure - 160/80mmHg
Respiratory rate - 34 cpm
SpO2 92 at room air
Temperature afebrile
Systemic examination
Patient examined in sitting position.
Respiratory system:
Inspection:
No tracheal deviation
Chest bilaterally symmetrical
Type of respiration: thoraco abdominal.
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.
Palpation:
No tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Tenderness over chestwall- Absent.
Vocal fremitus- normal on both sides.
Percussion:
Supraclavicular
Infraclavicular.
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapula
Interscapular
Right side and left side- resonant in above areas.
Auscultation:
Bilateral Basal crepitations heard
Diffuse wheeze also present
Cardiovascular system:
Auscultation:
Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.
No murmurs
No thrills
Abdominal examination:
Abdomen shape - Scaphoid, umbilicus- inverted
Soft, No tenderness.
No organomegaly.
Umbilicus inverted
All quadrants of abdomen area moving normally
Palpation
Liver not palpable
Spleen not palpable
Bowel sounds heard on auscultation
Investigations
10/06/2022
HbsAg.
Hiv serology - Negative
11/06/2022
Chest Xray
Ultrasound ;
Provisional Diagnosis:
Chronic kidney disease with Pulmonary edema
Denovo Type 2 Diabetes mellitus.
Treatment
Dialysis was done after admission.
10/6/22
1)Inj.LASIX 40mg IV/BD
2)tab.NODOSIS 500mg PO/OD
3)tab.MET-XL 25 mg OD
4)tab.AMLONG 10mgOD
5)cap bio-D PO weekly once
6)tab. SHELCAL 500 mg PO OD
7)inj. Erythropoietin 5000 units weekly once
11/6/22
1)Inj.LASIX 40mg IV/BD
2)tab.NODOSIS 500mg PO/OD
3)tab.MET-XL 25 mg OD
4)tab.AMLONG 10mgOD
5)cap bio-D PO weekly once
6)tab. SHELCAL 500 mg PO OD
7)inj. Erythropoietin 5000 units weekly once
8)inj.INSULIN SC according to the GRBS
Comments
Post a Comment