1701006179 CASE PRESENTATION

LONG  CASE:  

55 years old female patient resident of choutuppal who have sedentary life came to the hospital on 10/6/22 with 

Chief complaints:

-Shortness of breath Since 2 days 

-Bilateral pedal edema since 2 days 

-Decreased urine output since 2 days 

Time line of events: 

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic six years back 

Then developed pedal edema  which is bilateral and body pains ,for which she visited hospital and diagnosed with hypertension and renal failure and on conservative management 

2 years back ,  she admitted in hospital for 2 days as she have giddiness and fever 

Recurrent episodes of fever occur which temporarily relieved on medication 

From past 2 days 

—patient developed shortness of breath grade 4  sudden in onset,  not associated with chest pain  ,sweating 

—Bilateral pedal edema   which is pitting type 

—Decreased urinary output not associated with        burning micturition 

- constipation 

Past history: 

Known case of hypertension since 6years

Known case of chronic kidney disease since 6 years 

diabetes mellitus type -2( diagnosed after coming to our hospital) — GRBS ( random glucose test ) is 418mg% 

Not a known case of Asthma,TB ,CAD, epilepsy 

No history of surgeries in the past

No  history of blood  transfusions.

Personal history:

Diet -mixed 

Appetite -normal

Sleep -adequate 

Bowelmovements-irregular since 2 days 

Bladder movements-decreased urinary output since 2days

No known drug or food allergies 

No addictions

Family history:

No significant family history

General examination: 

After taking consent ,patient is examined in well lit room

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

moderately  built and moderately  nourished 

Pallor- present 

Icterus -absent 

Clubbing -absent

Cyanosis -absent 

Generalised lymphadenopathy -absent 

Edema- present  

VITALS:-

Temperature-afebrile

Pulse rate -106 beats per minute ,regular rhythm ,normal volume,normal character ,no radio radial delay

Blood pressure -160/80mmHg measured in left arm in supine position 

Respiratory rate -34 cycles per minute

SpO2- 92 %at room air 

 Systemic examination:

Respiratory system:

Upper respiratory system - normal

Examination of chest-

Inspection:

Shape of the chest -normal, bilaterally symmetrical

Trachea -central in position 

Respiratory movements -normal, bilaterally symmetrical

No scars,sinuses, engorged veins seen on chest wall

Palpation:

No local rise of temperature

No tenderness 

All inspectory findings are confirmed

Trachea -central in position

vocal Fremitus - normal 

Chest movements - normal ,symmetrical bilaterally

Percussion:

Resonant note heard

Auscultation: 

Bilateral air entry present

Normal vesicular breath sounds heard

Bilateral basal crepitations  heard at infrascapular and infra axillary 

Cardiovascular  system :  

 S1  S2  heard , no added sounds are heard , no murmurs  are heard 

Abdominal examination:

Per abdominal- normal and non tender , no Organomegaly 

Central nervous system examination- 

Higher mental functions -normal

 Cranial nerves-Normal

Sensory and motor examination- normal

Reflexes-normal 

Investigations 

Hemogram: 

10/ 6 / 22

 11/06/22

Ultrasonography - 

Right Grade 3 RPD

Left Grade 2 RPD

ECG : 

11/6/22

10/6/22

PROVISIONAL DIAGNOSIS : 

Chronic renal disease with  pulmonary edema and metabolic acidosis with denovo diabetes mellitus type-2

Treatment:- Dialysis was done after admission in hospital

1)Inj.LASIX 40mg IV/BD

2)tab.NODOSIS 500mg PO/OD

3)tab.MET-XL 25 mg OD

4)tab.AMLONG 10mgOD

5)cap bio-D PO weekly once 

6)tab. SHELCAL 500 mg PO OD

7)inj. Erythropoietin 5000 units weekly once 

8)inj.INSULIN SC according to the GRBS

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SHORT  CASE: 

A 75 Year old female, who is  farmer by occupation, resident of Nalgonda , came to the hospital on 9/6/22  with 

CHIEF COMPLAINTS:

1. Nausea and vomitings since morning

2. Giddiness since morning

HISTORY OF PRESENTING ILLNESS:

Time line:

Patient was apparently asymptomatic 6 years back then she developed  Generalized weakness, headache for which she visited the hospital and was diagnosed with Diabetes and Hypertension  for which medication was prescribed . Since 4 days she didn't take her medications as she went to visit her relatives. 

She came to the hospital with complaints  of 2-3 episodes of vomiting, non-bilious, non-projectile, followed by giddiness. 

She was taken to a local hospital primary, where she was found to have GRBS-394 mg/dl and ketone bodies +ve. 

No h/o Chest pain, palpitations, syncopial attacks.

No h/o Shortness of Breath.

No h/o Pain abdomen, burning micturition or loose stools.

PAST HISTORY 

No history of similar complaints in the past. 

Patient is a known case of HTN and DM and is on prescribed medications. 

H/o Cataract surgery in right eye 3 years ago and in left eye 2 years ago.

 Not a known case of  Bronchial asthma, Epilepsy, TB. 

PERSONAL HISTORY

DIET - Mixed

APPETITE- Normal

SLEEP - Adequate

BOWEL AND BLADDER- Regular

ADDICTIONS - No addictions

No known 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, clubbing, cyanosis, lymphadenopathy, edema.

VITALS 

BLOOD PRESSURE: 230/100 mmHg

GRBS: 393mg/dl 

PULSE PRESSURE: 90 Bpm

RESPIRATORY RATE: 18cpm

TEMPERATURE: Aferbile

SpO2: 97% on Room air

SYSTEMIC EXAMINATION

1. RESPIRATORY SYSTEM: Normal Vesicular breath sounds heard.

2. CARDIOVASCULAR SYSTEM: S1 and S2 Heard, no murmurs.

3. CENTRAL NERVOUS SYSTEM: No focal neurological deficits.

4. PER ABDOMEN: Soft, non- tender, no abdominal mass.

INVESTIGATIONS 

 RBS - 164 mg/dl

BLOOD UREA - 26 mg/dl8

 SERUM CREATININE- 1.0 mg/dl

 URINE EXAMINATION 

• Albumin: ++
• Sugar: ++++
• Pus cells-3 to 6
• Epithelial cells -2 to 4

URINE FOR KETONE BODIES - 

On 9/06/2022

Positive 

On 11/06/2022

Negative 

HEMOGRAM 

• Hemoglobin: 11.3mg/dl 

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   

ABG Analysis

• pH     : 7.44
• pCO2 : 30.6mmHg
• pO2.  :71.4mmHg
• HCO3:22.6mmol/L
• O2sat:93.8%

    Seronegative for HIV, HEPATITIS B and C

     USG- Mild hepatomegaly

     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
7. Strict input output charting

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
7. Strict Input output 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. BP 2nd hourly charting
7. Strict input/output charting

12/06/2022

1. Injection Human actrapid insulin 12/12/12 and NPH 10/-/10, Strict GRBS monitoring 
2. Inj. OPTINEURON 1 ampoule in  NS (IV)/ OD
3. Inj. ZOFER 4mg IV/ TID
4. Tab CINOD-T (40/10) mg PO OD
5.  BP 2nd hourly charting
6. Strict input/output charting

13/06/2022

1. Injection Human actrapid insulin 12/12/12 and NPH 10/-/10, Strict GRBS monitoring 
2. Inj. OPTINEURON 1 ampoule in  NS (IV)/ OD
3. Inj. ZOFER 4mg IV/ TID
4. Tab CINOD-T (40/10) mg PO OD
5.  BP 2nd hourly charting
6. Strict input/output charting