1701006169 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 Presenting 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 diabetic mellitus and hypertension. She used medication for the same which was prescribed.


4 days back the patient stopped taking anti hypertensives and oral hypoglycemic agents 

Due to which she had 2-3 episodes of vomiting which was non bilious and non projectile and contained food particles, which was followed by giddiness.

Then she was taken to a local hospital, where she found her GRBS was 394 mg/dl and her urine sample was positive for KetoneBodies.

(Then she was referred to our Hospital).


No complaints of shortness of breath, chest pain, palpitations, syncopal attacks.

No complaints of burning micturition, loose stools, abdominal pain. 


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:


Diet: Consumes both Veg and Non-Vegetarian Foods.

Appetite:Normal

Sleep:Adequate 

Bowel and Bladder movements:Regular

Consumes Alcohol occasionally (90ml)

No history of any allergies. 


Family History:


Insignificant


Treatment History:


History of usage of oral hypoglycemic agents and anti hypertensive drugs


General Examination:


After taking informed consent patient was examined in a well lit room.

Patient was conscious coherent cooperative moderately built and nourished and well oriented to time place and person. 


Vitals: On 9th June 2022


Temperature: 99°F

Respiratory Rate:18cpm

Pulse Rate:96bpm

Blood pressure:230/100 mmhg

SpO2:97% on room air

GRBS:393mg/dl

No Signs of Pallor,Icterus,Cyanosis,Clubbing,Lymphadenopathy, Edema










Systemic Examination:


Respiratory system:Normal Vesicular Breath Sounds 

Bilateral Air Entry present


Cardiovascular system:S1 and S2 heard, No added murmurs


Central Nervous System: No focal Neural Deficit


PerAbdomen: Soft,Non Tender, No Abdominal Mass seen


Investigations:

Random blood sugar: 164mg/dl

Blood Urea: 26mg/fl

Serum Creatinine: 1.0 mg/dl

Electrolytes: 

Sodium - 139mEq/L  

Potassium- 3.3mEq/L.                                 

Chloride -98mEq/L


Complete urine examination:

Albumin: ++

Sugar: ++++

Pus cells: 3-6 /HPF

Epithelial cells: 2-4 / HPF

Red blood cell: NIL

Casts: NIL


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


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


Arterial blood gas:

pH: 7.44

pCO2: 30.6mmHg

pO2: 71.4mmHg

HCO3: 22.6mmol/L

O2sat:93.8%


Urine KETONE BODIES POSITIVE 

Glycated Hemoglobin: 6.5%

Seronegative for HIV, HEPATITIS B and C





ECG:





X-Ray: 








Provisional Diagnosis:


Diabetic ketosis with Hypertensive Urgency


Treatment:


Inj-Zofer (4mg I/V TID)

Inj-Pantop (40mg I/V OD)

Inj-Optinuron/NS (1 ampule/100ml I/V OD)

Tab-Nicardia (10mg PO)

Tab-Telma-Am (40/5 mg)

Inj-Human Actrapid Insulin (6 ml/hr I/V)



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



SHORT CASE:



A 25 year old female patient who is a housewife and resident of Miryalaguda came to OPD with cheif complaints of 

CHEIF COMPLAINTS:
High blood pressure ( came for checkup )

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 year back then she developed hypertension which was found out on her 1 St pregnancy. She had 2 abortions in the past i.e in 1 year back in 2021 and 5 months back in 2022 .Her obstetric formula is P2A2L0. 

In 1st pregnancy i.e 1 year back in 2021 when the patient conceived she visited obstetrician and found out to have hypertension which was 150/100 mmhg.She had history of pedal edema. She was started on anti hypertensive drugs i.e tablet labetalol 100 mg PO BD. At around 8 months, patient had Intrauterine death of fetus and baby was delivered by normal vaginal delivery. 

Then she stopped taking anti hypertensive drugs.After a gap of 3 months she conceived again in 2022.
In 2nd pregnancy i.e 5 months back in 2022 she conceived and found out to have hypertension which was160/100mmhg. She was started on anti hypertensive drugs i.e tablet labetalol 100mg PO BD. At around 8 months preterm delivery which was done by normal vaginal delivery, the baby died within 1 day.
Now the patient has no history of palpitations, shortness of breath, pedal edema, decreased urine output, headache, blurring of vision.

PAST HISTORY:

History of hypertension since one year
No history of Diabetes mellitus, Tuberculosis, Asthma, CAD
No history of blood transfusion
No history of previous surgeries

TREATMENT HISTORY:
History of usage of anti hypertensive drugs i.e labetalol. 

PERSONAL HISTORY:
Diet : Consume both Veg and Non-Vegetarian foods
Appetite: normal
Bowel and bladder : regular
Sleep : adequate
No addictions
No allergies

FAMILY HISTORY:
No significant family history.

GENERAL EXAMINATION:
After taking informed consent the patient was examined in a well lit room. 
On Examination: Patient is Conscious, Coherent and Cooperative well oriented to time, place and person
Clubbing - absent
Pallor - absent
Icterus - absent
Cyanosis - absent
Edema of feet - absent
Lymphadenopathy - absent

VITALS:- 
On admission i.e on 8-6-22 :
 Temperature: afebrile
  BP: 170/100 mm hg 
  PR: 90 bpm
  RR: 22 cpm
  SPO2: 98%
  GRBS: 164 mg%

On 11-6-22:
Temperature: afebrile
BP: 160/100mmhg
 PR: 98 bpm 
 RR: 16 cpm 
 
On 12-6-22 :
 Temperature: afebrile
 BP: 120/80mmhg
 PR: 74 bpm 
 RR: 16 cpm 










 
SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM :
 S1 and S2 heard, no murmurs heard
 
RESPIRATORY SYSTEM :
 BAE present, NVBS heard, position of trachea - central

PER ABDOMEN : 
soft, non tender.
No organomegaly.

CNS: 
Higher mental function intact,NAD.

INVESTIGATIONS:
Blood urea : 19



Serum creatinine: 0.8


CBP


Hb: 14.1
TLC: 9,900
Neutrophils: 65
Leucocytes: 30
PCV : 40.4 
MCV: 85.4
MCHC: 34.9
Platelet count: 3.64
RBC: Normocytic normochromic

Ultrasound Abdomen


On 8-6-22:
Na - 142
K - 3.8
Chloride- 103

Complete Urine Examination:
Albumin- trace 

LFT: 
SGOT: 20
SGPT: 30
ALP: 218
Total Protein: 7.6 
Albumin: 4.18 
A/G ratio: 1.22

Thyroid Profile:
T3- 1.32
T4- 10.75
TSH- 2.32

Lipid Profile: 
Total cholesterol-204
Triglycerides-201
HDL- 55
LDL-120
VLDL-40.2

Chest X-ray:



PROVISIONAL DIAGNOSIS:

YOUNG ONSET HYPERTENSION

TREATMENT:
1) Tablet. AMLONG 5 mg PO OD 
2) Tablet. Zincovit PO OD.

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