1701006136 CASE PRESENTATION

 LONG  CASE  

A 59 years old female who is a house maker resident of nalgonda came to the opd with chief complaints of  

• Generalized weakness since 6 months 

• Facial puffiness and swelling of legs  since 6months 

• Decreased urinary output since 3 months

                Time line of events 

 



History of present illness :- 

Patient was apparently asymptomatic 1year back later she went to a local rmp for regular checkup and there she was diagnosed with hypertension and was on medication 

Tab nifidepine 10mg

Tab furosemide 40mg

6 months back  patient complaint of decreased food intake , weakness , puffiness of face and legs so went to near by hospital. But there was no improvement  

5 months back  they went to Miralguda hospital  with weakness , reduced food intake,  reduced urinary output , and puffiness of face and swelling of legs which is pitting type below the knees , doctor told that her kidneys were not functioning properly so she was put on medication as there was no improvement 

They came to Kamineni Hospital in the month of April  

Here the patient was put on dialysis which was done weekly 2 times.



Daily routine :- 

Patient usually wakes up at 5 am and will do household works  and  have breakfast along with coffee at 8:00 am again continues her household work and then she will have her lunch which is  rice and dal at 1:00pm and then takes a nap again continues her work then will have her dinner which is rice and dal at 8:30 pm and goes for sleep at 10:00pm 

Past history:- 

Known case of hypertension since 1 year

 Not a known case of Diabetes mellitus, asthma, epilepsy, TB

No history of similar complaints in the past

No previous surgical history


Personal history:- 

Diet- Mixed

Appetite- Decreased since 1month 

Bowel :- Regular 

Bladder movements- Urine frequency is reduced since 3 months  

Sleep- Adequate

No Addictions

No history of drug or food allergies


Family history :-

No similar complaints in the family


General examination

Done after obtaining consent, in the presence of attendant with adequate exposure

Patient is conscious, coherent, cooperative and well oriented to time, place and person

Patient is  well nourished and  moderately built

Pallor - present

Pedal edema- present- bilateral pitting type

No history of  cyanosis, clubbing and lymphadenopathy


Vitals

Temperature- Afebrile

Blood pressure- 150/90 mm of Hg

Pulse rate- 86 bpm

Respiratory rate- 21 cpm

SpO2 - 98% at room air 


Systemic examination :- 

• Abdomen examination:- 

On Inspection:

-Shape of the abdomen -Distended

-Movements of abdominal wall- moves with respiration

-Skin is smooth

-No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites

On Palpation:

-Inspectory findings are confirmed

-Soft and non tender

-No palpable mass

-No hepatosplenomegaly

On percussion:

 -Dullness is noted 

On auscultation:

-Bowel sounds heard


• Cardiovascular system examination:

-S1 and S2 sounds are heard

-No murmurs


• Respiratory system examination:

-Bilateral air entry present

-Normal vesicular breath sounds are heard


• Central nervous system examination:

-No focal neurological deficits


Clinical pictures :- 













Investigations:- 

Complete blood picture:-

Hemoglobin :-4.5 gm/dl 

Total count :- 7000 cells/cumm 

Neutrophils :- 86% 

Lymphocytes :- 12%

 Eosinophils :- 0% 

Monocytes :- 02 %

Basophils : 0 % 

PCV :- 13.7 vol % 

MCV :- 83.5 fl

 MCH :- 27.4 pg 

MCHC :- 32.8 % 

RDW-CV :- 15.8 %

RDW -SD :- 47.5 fl

RBC count :- 1.64 millions/ cumm

Platelet count :- 28000


Impression :- Normocytic normochromic anemia with neutrophilia, thrombocytopenia












Provisional diagnosis :- 

Chronic kidney disease secondary to hypertensive nephropathy ?


Treatment :- 



2nd June 


1. Tab Nodosis 550mg/PD/TID 

2. Tab Pan 40mg /PR/OD 

3. Tab Lasix 4mg/Pd/BD 

4, Tab Nicardia 10mg/PO/BD 

5. Tab Arkamine 0.1mg/PD/OD 

6. Tab Zofar 4mg /PD/SOS 

7. Tab MVT /PD/OD 

8. 2 PNBC 1 SPP Reserve 

9. 1PNBC intradialysis transfusion 

10. 1 SDP Transfusion



3rd June 


1. Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT/ PD/OD 

9. 1 PRBC reverse and 1 CDI Transfusion 

10. Inform SOS 

11. 1 PRBC transfusion intradialysis



4th June 


1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT /PD/OD 

9. 1 PNBC intra dialysis planned for tomorrow morning



5th June 


1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT /PD/OD



6th June 


1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT /PD/OD



7th June 


1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT /PD/OD


8th June 


1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT /PD/OD


9th June 


1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT /PD/OD










Instrument pictures :- 















--------------------------------------------------------

SHORT  CASE 

75 years old female home maker by occupation, resident of dhamarcherla was bought to the casuality with

• chief complaints of vomitings and giddiness since 1 day. 


HISTORY OF PRESENTING ILLNESS :

•Patient is a known case of diabetes mellitus and hypertension since 6 years. 

•She was apparently asymptomatic 6 years back. 
Later she had complaints of headache, generalized weakness for which she was taken to a hospital and there she was diagnosed with diabetes mellitus and hypertension and prescribed on oral medication. From then she was on regular medication. 

• Patient did not use oral hypoglycemics and anti- hypertensives for the past 4 days as she went to relatives house. 

• Patient presented with  2-3 episodes of vomitings, non- bilious and non - projectile followed which she developed giddiness. Contents of the vomitus are food and it is not foul smelling. No history of fever or pain abdomen.She was taken to a local hospital where it was found out that her GRBS is 394mg/dL and ketone bodies were positive and referred to our hospital. 

• No history of shortness of breath, chest pain, palpitations. 



PAST HISTORY :

She is a known case of diabetes mellitus and hypertension since 6 years. 

No history of Tuberculosis, cardiovascular disease. 

Surgical history - history of cataract surgery 3years back in one eye and 2 years back in the other eye. 


PERSONAL HISTORY :

Diet - mixed

Appetite - normal

Sleep - adequate 

Bowel and bladder movements - regular

 Addictions - chutta smoking for 10years , 3 chutta per day and stopped  5 years back. 

No allergies 

FAMILY HISTORY : 

Not significant


MENSTRUAL AND OBSTETRIC HISTORY :

Attained menopause
8 children - 4 boys and 4 girls


GENERAL EXAMINATION :

Patient was examined in a well lit room after taking informed consent. 
She was conscious, coherent and cooperative. 
Oriented to time, place and person. 

Pallor - present

Icterus - absent

Cyanosis - absent

Clubbing - absent 

Generalized lymphadenopathy - absent

Bilateral pedal edema - absent









VITALS : 

Pulse - 96 beats per minute, irregularly irregular in rhythm,  no radio-radial delay, no radio- femoral delay. 

Blood pressure - 230/100 mm of hg measured in left arm in supine position 

Respiratory rate - 17 cycles per minute

Temperature - Afebrile 

GRBS - 393 mg/dL


SYSTEMIC EXAMINATION :

CVS : 

Inspection : no visible pulsation , no visible apex beat , no visible scars.


Palpation: apex beat felt.

Auscultation: 
Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

CNS : 

Intact

 

Respiratory system: 

Inspection:

No tracheal deviation 
Chest bilaterally symmetrical
Type of respiration:  thoraco abdominal.
No dilated veins,pulsations,scars, sinuses.

Palpation:
No tracheal deviation
Vocal fremitus- normal on both sides.

Percussion:                   
Resonant in all areas

Auscultation:
 Normal Vesicular breath sounds
Bilateral Airway entry - present.

ABDOMINAL EXAMINATION : 

INSPECTION :

Abdomen -  distension present
Umbilicus - normal
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 
No organomegaly 

PERCUSSION :

no shifting dullness 

AUSCULTATION :

Bowel sounds are heard and are normal
No bruit.




INVESTIGATIONS :

Haemogram :

  Hb - 11.3 g/dL

  TLC - 8100 

  Platelets - 2.67 lakhs 

  Normocytic normochromic anaemia


Complete urine examination :

 Albumin - 2+

 Sugar - 4+

 Pus cells - 3-6

 Epithelial cells - 2-4

 RBC  -  nil

 Casts - nil


Urine for ketone bodies - positive


Arterial blood gas analysis : 

 PH - 7.44

 Co2 - 30.6

 O2- 71.4

 Hco3 - 22.6

  O2 Saturation - 94%


Electrolytes : 

 Sodium - 133 mEq/dL

 Potassium - 4.2 mEq/ dL

 Chloride - 102 mEq/ dL


10/6/22 

Electrolytes 

Sodium :- 136 

Potassium :- 4.2 

Chloride :- 102 


10/6/22 

Complete urine examination :- 


Albumin :- + 

Sugars :- nil

Pus cells :- 3-6 cells 

Epithelial cells :- 2-3 cells 

RBC :- nil

Cast :- nil 



11/6/22 

Serum electrolytes :- 

Sodium :- 134 

Potassium :- 3.6 

Chloride :- 99


Blood urea - 26mg/dL

Serum creatinine - 1mg/dL


Ecg : 







 DIAGNOSIS : 

Diabetic ketosis with  hypertensive urgency

TREATMENT :

• Intra venous fluids( NS, RL) - 100ml /hr

• HUMAN ACTRAPID insulin infusion -6ml/hr

• Tab. NICARDIA 20mg PO/stat

• Inj. OPTINEURON -1 ampoule in 100ml of NS        IV/OD

• Inj. ZOFER 4mg IV / TID

• Hourly monitoring of grbs, pulse, bp, rr, and temperature. 










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