1701006145 CASE PRESENTATION
LONG CASE:
A 75 year old female, who is a resident of miryalaguda was brought to the OPD with chief complaints of
- Vomiting since 1 day
- Giddiness since 1 day
Patient was apparently asymptomatic 4 years back and was able to perform her regular work as an agricultural worker when she developed gradual diminision of vision (in both eyes) along with generalised weakness and headache for which she was taken to a nearby hospital and underwent bilateral cataract surgery. At the same time she was diagnosed with Type 2 Diabetes Mellitus and Hypertension for which she started regular medication ever since.
4 days back she visited her daughters house and forgot to take her medication for Diabetes Mellitus and Hypertension subsequent to which she developed giddiness and vomiting which was sudden in onset, non projectile, non bilious and non foul smelling containing food particles as content.
Not associated with fever, abdominal pain, loose stools or rapid breathing with fruity odour.
On taking her to hospital 1 she was found to have a GRBS of 394 mg/dl and urinary ketones was found to be positive for which she was referred to hospital 2 and admitted.
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 TB, Asthma, Epilepsy or CAD.
Surgical History
Underwent bilateral cataract surgery 4 years back.
Personal History
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder- regular
Addictions- smoked chutta for 10 years; 3 Chuttas per day; stopped 4 years back
Family History
Not significant
No h/o TB, asthma, epilepsy
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative.
She is well oriented to time, place and person.
Moderately built and nourished.
Patient was examined in supine position in a well lighted room after taking consent.
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Edema - absent
Temperature - afebrile
Pulse rate - 90 beats per minute; regular rate and rhythm
All Superficial pulses- intact
Respiratory rate - 20 cycles per minute
Blood pressure - 230/110mmHg at the time of presentation(around 7pm) on Day 1
On day 2 - Blood pressure - 150/100mmHg
On day 3- Blood pressure - 180/100 mm Hg
GRBS - 394mg/dl ( at presentation) Day 1
On day 2 - 226mg/dl
On day 3-
SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM EXAMINATION
Level of consciousness- conscious/ alert
Higher mental functions- normal
Speech- Normal
Cranial nerve functions - Intact.
Sensory system-
R. L
pain N. N
Temperature N. N
Superficial touch N. N
vibration N. N
Proprioception N. N
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 Reflex- R- flexion L- flexion
Deep tendon reflexes -
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
Gait- Normal
Cerebellar system - intact
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 - bimanually palpable kidneys
Percussion-
no shifting dullness
Auscultation-
Bowel sounds are heard and are normal
No bruit.
Respiratory system
Inspection
No tracheal deviation
Chest bilaterally symmetrical
Type of respiration: thoraco abdominal.
No dilated veins,pulsations,scars, sinuses.
Palpation:
No tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Tenderness over chestwall- absent.
Vocal fremitus- normal on both sides.
Percussion:
Right side and left side- resonant
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.
DIAGNOSIS
Hyperglycaemia and Hypertensive Urgency
(2⁰ to non compliance to medication)
INVESTIGATIONS
Investigations prior to admission at hospital 2-
Urinary Ketones- Postive
GRBS - 394 gm/dl
Investigations on admission to Hospital 2
GRBS CHARTING-
On day 1- at presentation- 394 mg/dl
On Day 2- 226 mg/dl
On day 3- 214 mg/dl
On day 4- 199 mg/dl
A 22 year old female resident of miryalguda and daily wage labourer by occupation presented with chief complaints of no urine output since 5 days and generalised edema since 5 days
Patient was apparently asymptomatic 12 years ago when she developed an episode of fever which was associated with increased appetite and increased frequency of micturition for which she was taken to a nearby hospital and was diagnosed with diabetes. She has been on regular medication ever since. She was initially kept on oral hypoglycaemics for 1 year but later was kept on insulin 2 times per day.
3 years back she had an episode of altered sensorium for which she was taken to the hospital. She was found to be hyperglycaemic and the dose of insulin was increased.
20 days back she was bought to the opd with generalized edema , decreased urine output and diagnosed with renal failure and nephrotic syndrome. She underwent 5 cycles of dialysis and 1 unit of blood transfusion was done. She got discharged but got admitted again for the same complaints.
The edema was initially around the eyes which was more in the morning and decreased towards the end of the day. Later it progressed to involve the entire body.Decreased urine output since 15 days which progressed to no urine output since 5 days.
No hematuria, No loin pain, No history of fever or sore throat recently.
PAST HISTORY :
Patient is a known case of diabetes since 12 years and hypertension since 1 year.
No h/o Tb, epilepsy, asthma
No previous surgical history
FAMILY HISTORY :
No history of diabetes or hypertension in the family
PERSONAL HISTORY :
Diet - mixed diet
Appetite - decreased appetite since 6 months
Sleep - adequate
Bowel movements - regular
Bladder movements - normal before 20 days
No addictions
No food or drug allergies
GENERAL EXAMINATION :
Patient is examined in a well lit room after taking the consent.
She is conscious, coherent and cooperative.
Well oriented to time, place and person.
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Generalized Lymphadenopathy - absent
Bilateral pedal edema - present
She has generalized edema ( anasarca)
VITALS :
Pulse - 88 beats per minute, regular rate and rhythm
Respiratory rate - 20 cycles per minute
Blood pressure - 140/80 mm of hg
Temperature - afebrile
Spo2 - 96% at room air
GRBS - 203 mg/dL
SYSTEMIC EXAMINATION :
CVS :
S1 S2 heard, no murmurs
CNS :
No neurological deficit
ABDOMINAL EXAMINATION :
Inspection - abdomen distended
Umbilicus is normal in shape and position
No visible scars or sinuses
No visible gastric peristalsis
No distended veins
Palpation - No local rise of temperature
No tenderness
Organs- not palpable
Percussion - fluid thrill present
Auscultation - bowel sounds normal
RESPIRATORY EXAMINATION :
Inspection - Trachea is central in position.
Chest is symmetrical.
Movement of the chest is equal and thoraco-abdominal type of breathing.
Palpation - Trachea is central in position.
Chest is expanding symmetrically.
Vocal fremitus decreased inframammary, infraaxillary and infrascapular areas on both sides.
Percussion - Stony dull note in inframammary, infraaxillary, infrascapular area on both sides.
Auscultation - Bilateral air entry present.
Normal vesicular breath sounds.
Decreased breath sounds in inframammary, infraaxillary, infrascapular areas on both sides.
INVESTIGATIONS
on admission -Day1
Ultrasound report-
Chest Radiography-
On Day 3 of admission
DIAGNOSIS :
Chronic kidney disease on maintenance hemodialysis with bilateral pleural effusion.
TREATMENT :
• Inj. LASIX 60mg/ IV/ BD
• INSULIN INFUSION 6ml / hr
1ml of insulin in 39ml of normal saline
• Tab. NICARDIA 20mg/ PO / BD
• Tab. TELMA 40mg/ PO / BD
• Nil by mouth
• Fluid and salt restriction
• Hourly monitoring of GRBS
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