1701006143 CASE PRESENTATION

LONG CASE:

29 years old female came to the casualty with chief complaints of -

        Joint pains since 6 months

        Pigmentation over face 6 months

        Oral ulcers since 5 months

History of presenting illness :

Patient was apparently asymptomatic 6months back, then she complained of joint pains which are insidious in onset   associated with morning stiffness and low grade fever, no aggrevating and relieving factors 15 days later she complained of lesion over the face and diffuse loss of hair.

History of pedal edema

History of loss of appetite 

History of apthous ulcers 5months back

History of nausea and vomitings 

No history of photosensitivity 

Raynauds Phenomenon

Past history:

NO HISTORY OF ASTHMA

NO HISTORY OF SEZIURES 

NO HISTORY OF DIABETES MELLITUS 

NO HISTORY OF HTN 

PREVIOUS SURGERIES : HYSTERECTOMY 

PERSONAL HISTORY : 

DIET : MIXED 

APPETITE : REDUCED

SLEEP : INADEQUATE  

BOWEL AND BLADDER : REGULAR

NO ADDICTIONS AND ALLERGIES

GENERAL EXAMINATION: 

PATIENT IS CONSCIOUS COHERENT COOOPERTIVE

Well oriented to time place person

Moderately bulid and moderately nourished

No pallor,icterus, cyanosis, clubbing,koilonychia,generalised lymphadenopathy

BILATERAL PEDAL EDEMA  +

VITALS :

BP - 110 / 70 mmhg

PR - 86 bpm

Respiratory rate- 15 cycles/min

SPO2 - 99% @RA

TEMP - 99.3 F

SYSTEMIC EXAMINATION :

CVS - S1 S2 +

RS - BAE +

CNS : NAD

Per Abdomen-soft non tender

                          No organomegaly

INVESTIGATIONS:

Provisional diagnosis : SYSTEMIC LUPUS ERYTHEMATOSUS .

Treatment:

DAY 1

PHOTO BAN CREAM (TID)

TAB CLONAZEPAM 0.5MG

DAY 2

TAB ULTRACET1/2 TAB OID

WYSOLONE 20MG OD

TAB HCQ 10MGBD

DAY 3

TAB ULTRACET 1/2 TAB OD

TAB HCQ 10MG BD

ING NEOMAL 1G I. V

TAB WYSOLONE:20 MG OD

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SHORT CASE:

A 75 year old male farmer by occupation came to the casualty on morning with the cheif complaints of:

- decreased responsiveness since 5am on     and was not able to speak 

History of presenting illness:

Patient was apparently asymptomatic 5days back later on 7/6/22 he was unable to speak followed by loss of consciousness for which he was brought to our hospital and his GRBS was recorded low ( 43 mg/dl)

Last 2 days he had not taken any meals and consumed alcohol and later he had complaints of excessive sweating, tremors, generalised weakness, lethargy, fatigue 

He also had decreased urine output,

No history of headache, blurring of vision, nausea, vomiting, abdominal pain and loose stools 

Past history:

15years ago he had fever, weakness and increased urine output and was diagnosed as type 2 diabetes mellitus and was on OHAs since 15years 

6years ago he had similar complaints i.e decreased responsiveness due to low grbs and was treated in a local hospital with IV fluids. 

2years ago he underwent cataract surgery in his left eye 

Not a k/c/o Hypertension, TB, Epilepsy, Asthma

Personal history:

Diet- Mixed

Appetite- normal

Sleep- Adequate 

Bowl habits- regular

Bladder- increased urine output

Addictions- chronic alcoholic since 45years (90ml whiskey consumed daily) 

General examination:

Patient was unconscious at time of presentation.

Now he is conscious, coherent, cooperative, well oriented to time, place and person, moderately built and nourished 

Pallor- present

No icterus, cyanosis, clubbing, lymphadenopathy, edema

Systemic examination

Cvs- s1 s2 heard, apex beat normal, no murmurs or bruit 

Respiratory system- Normal vesicular breathe sounds heard

Abdomen- soft, non tender, no organomegaly 

Cns- 

Level of consciousness: normal

Speech : normal

Memory;  normal, no meningeal signs

INVESTIGATIONS:

Complete Blood Picture:

HB ; 10.9

Total leucocyte count;

7100

Neutrophils- 85

Lymphocytes- 10

Eosinophils-2

Monocytes- 3

Basophils-0

PCV-33.1

MCV- 81.9

MCH-27

MCHC-32.9

RDW-13.7

RBC-4.04

Platelet count- 3.82

Random blood sugar-114

Renal function tests;

Blood urea,-55

Serum creatinine- 2.2

Serum sodium- 139

Serum potassium-3.4

Serum chloride- 98

Liver function tests:

Total bilirubin: 0.52

Direct bilirubin: 0.18

SGOT: 16

SGPT;13

Alkaline phosphatase; 98

Total protein: 5.8

Albumin; 3.6

A/G ; 1.65

Complete urine examination;

Color : pale yellow

Appearance: clear

Specific gravity: 1.010

Albumin: +

Sugar: nil

Bile salts; nil

Bile pigments: nil

Pus cells; 3-4

Epithelial cells: 2-3

RBC: nil

Crystals: nil

9/6/22

Fasting blood sugar; 70mg/dl

Ultrasound;

B/L Grade-2 renal parenchymal disease

Borderline prostatomegaly

ECG;

Provisional diagnosis;

 Altered sensorium ( improved) 2° to oral hypoglycemic agents induced hypoglycemia

Chronic kidney disease

Treatment;

1)IV fluids DNS @ 50ml/ hour continuous infusion

2) inj optineuron 1 ampoule in 100ml NS/IV/ of

3) inj 25% dextrose IV /sos if grbs <70mg/dl

4) inj pantop 40 mg/po/ of

5) grbs monitering hrly

6) if grbs < 70 or > 250mg/dl start insulin