1701006162 CASE PRESENTATION

LONG CASE:


 A 75 years old female, resident of nalgonda, came to casualty on 9th June 2022 with 

CHIEF COMPLAINTS:

Vomiting and giddiness since morning.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 6 years back then she had complaints of headache and generalised weakness, for which she visited hospital was diagnosed with type 2 diabetic mellitus and hypertension. She used medication for the same.( Glimepiride 1mg and metformin 500mg)

On 5th June 2022, patient went to her relatives and there she did not use oral hypoglycemic agents and anti hypertensive for 4 days, due to which on 9th June 2022 she had 2-3 episodes of vomiting, non bilious and non projectile, contains food particles  followed by giddiness. She was taken to local hospital, where she found her GRBS was  394mg/dL and her urine sample was positive for ketone bodies. (Referred to our hospital)
No complaints of shortness of breath, chest pain, palpitations, syncopal attacks.
No complaints of burning micturition, loose stools, pain abdomen.

PAST HISTORY:

No similar complaints in past.

Not a known case of tuberculosis, asthma, epilepsy and coronary artery disease.

History of cataract surgery 3 years ago in right eye and 2 years ago in left eye.

PERSONAL HISTORY:

  1. Diet:mixed
  2. Appetite: normal
  3. Sleep: adequate
  4. Bowel and bladder movements: regular
  5. Addictions:Consumes alcohol occasionally (90mL), smoked chutta for 10years, stopped 5 years back
  6. No history of allergies

FAMILY HISTORY:

INSIGNIFICANT

GENERAL EXAMINATION:

Patient was examined in a well lit room after taking informed consent. She is conscious, coherent and cooperative; moderately built and well nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS: on 9/06/2022
  1. Temperature: 99°F
  2. Respiratory rate: 18cpm
  3. Pulse rate: 90bpm regular volume and character , no radio radial and radiofemoral delay.
  4. Blood pressure: 230/100 mmHg
  5. SpO2: 97% on Room air
  6. GRBS: 393 mg/dL 







SYSTEMIC EXAMINATION:

  1. Respiratory system: Normal vesicular breath sounds heard.
  2. CVS: S1 and S2 heard, no murmurs.
  3. CNS: no focal neural deficit
  4. Per Abdomen: soft, non tender, no abdominal mass.

INVESTIGATIONS:

  1. Random blood sugar: 164mg/dl
  2. Blood Urea: 26mg/fl
  3. Serum Creatinine: 1.0 mg/dl
  4. Electrolytes: Sodium     - 139mEq/L                                 Potassium- 3.3mEq/L.                                 Chloride   -98mEq/L
  5. Complete urine examination:
  • Albumin: ++
  • Sugar: ++++
  • Pus cells: 3-6 /HPF
  • Epithelial cells: 2-4 / HPF
  • Red blood cell: NIL
  • Casts: NIL
     6. BLOOD PICTURE
  • Hemoglobin: 11.3mg/dl
  • Total leucocyte count: 8900cell/cumm
  • Neutrophils: 80
  • Lymphocytes:13
  • Eosinophils:02
  • Monocytes:05
  • Platelets: 2.67 lakhs/cumm
  • RBC: 4.47million/cumm
    7. LIVER FUNCTION TESTS:
  • Total bilirubin: 0.74mg/dl
  • Direct bilirubin: 0.18mg/dl
  • Aspartate transaminase: 29IU/L
  • Alkaline phosphate: 143IU/L
  • Alanine transaminase: 11IU/L
  • Total proteins: 7.7g/dl
  • Albumin: 4.1g/dl
  • A/G ratio: 1.16
      8.  Arterial blood gas:
  • pH     : 7.44
  • pCO2 : 30.6mmHg
  • pO2.  :71.4mmHg
  • HCO3:22.6mmol/L
  • O2sat:93.8%
     9. Urine KETONE BODIES POSITIVE 
   10. Glycated Hemoglobin: 6.5%
   11. Seronegative for HIV, HEPATITIS B and           C
   12. ECG:

PROVISIONAL DIAGNOSIS:


Diabetic ketosis with hypertensive urgency

TREATMENT: 

9/06/2022
  1. Intravenous fluids normal saline/ ringer lactate @100ml/hr
  2. Injection Human actrapid insulin I.V infusion @6ml/hr
  3. Inj. OPTINEURON 1 ampoule in 100ml NS (IV)/ OD
  4. Inj. ZOFER 4mg IV/ TID
  5. Tab. NICARDIA 20mg PO/ STAT
  6. Monitor GRBS, PR, BP, RR CHARTING hourly
10/06/2022
  1. Intravenous fluids NS 2 @ 100ML/hr
  2. Injection Human actrapid insulin I.V infusion @6ml/hr
  3. Inj. OPTINEURON 1 ampoule in 100ml NS (IV)/ OD
  4. Inj. ZOFER 4mg IV/ TID
  5. Tab TELMA- AM (40/5) mg PO OD
  6. MONITORING GRBS,BP,PR, RR CHARTING
11/06/2022
  1. Intravenous fluids NS 2 @ 75mL/hr
  2. Injection Human actrapid insuin 10/10/10 and  NPH 8/-/8 ,strict GRBS monitoring
  3. Inj. OPTINEURON 1 ampoule in  NS (IV)/ OD
  4. Inj. ZOFER 4mg IV/ TID
  5. Tab CINOD-T (40/10) mg PO OD
  6. MONITORING BP 2nd hourly charting








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


SHORT CASE:


A 52 year old male, resident of Nalgonda, farmer by occupation, came to hospital with

CHIEF COMPLAINTS:

Fever and abdominal tightness since 6 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 6 days ago when he developed,

1.Fever- insidious in onset and gradually progressing, low grade and continuous, not associated with chills and rigor. No aggravating factor and  relieved with medication given by local rmp doctor.

2.Abdominal tightness-  insidious in onset,not associated with pain ,vomiting and diarrhoea. He also complaints of weakness since 6 days and decreased appetite since 5 days. 

He was admitted into Nalgonda hospital for 2 days before getting admitted here he was diagnosed with thrombocytopenia with 17,000cells/mm³

No history of headache,joint pains,body pains.No history of rashes and bleeding tendencies.No history of weight loss.

PAST HISTORY:

No similar complaints in the past.

No history of diabetes mellitus, hypertension, tuberculosis, asthma and epilepsy 

PERSONAL HISTORY:

  1. Diet - Mixed.
  2. Appetite- decreased since 5 days.
  3. Sleep - adequate.
  4. Bowel and bladder- regular.
  5. Addictions: consumes Alcohol and toddy since 15 years.(consumed toddy i 5 days back)

FAMILY HISTORY:

No similar complaints in past.

No history of asthma, Diabetes mellitus, Hypertension and epilepsy.

GENERAL EXAMINATION:

Patient was examined in a well lit room after taking informed consent. He is conscious, coherent and cooperative; moderately built and well nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS:

  1. Pulse - 90 beats per minutee
  2. Respiratory rate - 20 cycles per minute.
  3. Temperature - afebrile.
  4. Blood pressure - 120/80 mmHg.
  5. Spo2 - 98%.
  6. GRBS - 110 mg/dl.
No pallor
Left eye:


Right eye:










SYSTEMIC EXAMINATION:

  1. ABDOMINAL EXAMINATION:

  • INSPECTION:

    1. Abdomen shape - distended
    2. Flanks full
    3. Umbilicus - normal
    4. No visible scars, sinuses , striae , engorged veins.
    5. No visible gastric peristalsis.
  • PALPATION:
  1. No local rise of temperature.
  2. No tenderness.
  3. Abdomen distended.
  4. Organs not palpable
  • PERCUSSION: Fluid thrill is present.

  • AUSCULTATION: 
  1. Normal bowel sounds heard.
  2. No bruit.

   2. RESPIRATORY EXAMINATION:
  • BAE Present.
  • Normal vesicular breath sounds heard.

   3.CVS EXAMINATION: S1 S2 Heard, no           murmurs.

   4.CNS EXAMINATION: No neurological deficit.

INVESTIGATION:

8/06/2022
  1. Hemogram:
  • Hemoglobin - 14.9 gm/dl.
  • Total leucocyte count- 10,500cells/ mm³.
  • Neutrophils- 43%
  • Lymphocytes- 48%.
  • Eosinophils - 01%.
  • Platelet count - 22000 cells/ cumm.
  • PCV - 42.2
   2.Blood urea-59 mg/dl
   3.Serum creatinine -1.6mg/dl
   4.Serum electrolytes:
  • Na:142 mEq/l
  • K:3.9mEq/l
  • Cl:103 mEq/l
  5.Liver function tests-

  • Total bilirubin-1.27 mg/dl
  • Direct bilirubin-0.44 mg/dl
  • AST-60 IU/L
  • ALT-47 IU/L
  • ALP-127IU/L
  • Total proteins- 5.9 gm/dl
  • Albumin-3.5g/dl
  • A/G ratio-1.48
   6.COMPLETE URINE EXAMINATION:
  • Albumin ++
  • Pus cells - 4-6
  • Epithelial cells - 2 -3.
  • NS1 ANTIGEN Test - Positive.
  • IgM and IgG - Negative.
  7.HIV RAPID TEST non reactive.
  8.HBsAg Rapid test - negative.
  9.Anti HCV antibodies - non reactive.
 10.  Ultrasound: interpretation
  •  Mild splenomegaly .
  • On right side mild pleural effusion.
  • Mild ascites.
  • Grade 2 fatty liver.
  • Gall bladder wall - edematous.
  9/06/2022

Hemogram:
  • Hemoglobin: 14.3gm/dl.
  • Wbc - 8200 cells/cumm
  • Neutrophils - 38%
  • Lymphocytes-51%.
  • Platelet count - 30,000/cumm.
  • PCV - 42.0
10/06/2022

1Hemogram:
  • Hemoglobin- 14 gm/ dl 
  • Tlc - 5680cells/cumm.
  • Neutrophils -35%
  • Lymphocytes - 54%.
  • Platelet count-84,000/cumm.
2.Serum creatinine- 1.2 mg/dl.

11/06/2022

1.Hemogram:

  • Wbc- 4800 cells/cumm.
  • Neutrophils - 40%
  • Lymphocytes-48%
  • Platelet count -60,000cells/cumm
  • Platelet count -76000cell/cumm.(Same day evening)
12/06/2022

Hemogram
  • Hb-15.3
  • Wbc - 7,100.
  • Neutrophils - 40%
  • Lympocytes -50%
  • Platelet count- 1 lakhcells/cumm.
  • PCV - 44.6

PROVISIONAL DIAGNOSIS:


Viral pyrexia with thrombocytopenia secondary to dengue NS1 POSITIVE with polyserositis 
(Right sided pleural effusion and mild ascites).

TREATMENT:

  1. Ivf NS/RL/DNS continuous at 100ml/hr
  2. Inj. PAN 40mg IV BD 
  3.  inj. ZOFER 4mg IV/SOS
  4. Inj. NEOMOL 1gm IV/SOS
  5. Tab. PCM 650 mg PO/ SOS
  6. Inj. OPTINEURON 1 Ampoule in 100ml NS IV/OD over 30mins.
13/06/2022
  1. Oral Fluids
  2. Tab.dolo650mg/po/sos.
  3. Tab.pan 10mg/po/od.
  4. Tab.doxycycline 100mg/po/bd.
  5. Tab.zincovit po/od 
  6. Vitals monitoring.


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