1701006189 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 5 years ago in right eye and 3 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 

S

I





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: 

9/06/202
  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 
12/06/2022
  1. Inj. HAI ,Strict GRBS monitoring 
  2. Inj. OPTINEURON 1amp i. 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. Inj. HAI 8am :- 12 units ; 2pm:-12units ; 8pm:-12units
  2. Inj NPH:- 8am:- 10 units ; 8 pm:- 10 units
  3. GRBC monitoring
  4. T. CINOD -T (40/10)mg PO OD 
  5. Inj. Optineuron 1 amp in 100ml ns( I.V )
  6. Inj. Zofer 4mg iv
  7. 2nd hrly BP charting
  8. STRICT INPUT/OUTPUT CHARTING
----------------------------------------------------------------------------------------------------------------

SHORT  CASE:  

Chief complaints::

60 yr old female labourer by occupation came with chief complaints of Loose stools since 15 days, vomitings since 10 days

History of present illness::

Loose stools since 15 days which was 8-10 episodes initially now since 4 days decreased to 4-5 episodes per day associated with abdominal pain in upper quadrant colicky in nature non radiating
Vomitings was of 2 episodes previously non bilious non projectile with food as content

Past history::

No history of similar complaints in past
H/o allergic reactions on both upper limbs
No history of diabetis mellitus, hypertension, asthma, Tuberculosis,CAD.

Personal history::

Diet :mixed
Appetite:normal
Sleep:Adequate
Bowel and bladder: normal
Addictions: occasionally toddy  

Surgical history:H/o hysterectomy 10 yrs back

General examination::

On taking prior consent patient was examined in a well lit room 

Patient was conscious coherent cooperative
Well oriented to time place person
Moderately nourished and  built

No pallor,icterus,cyanosis, kilonychia Lymphadenopathy,edema






Vitals::
Temperature: afebrile
Pulse:80bpm
Respiratory rate:16cpm
Bp:110/80mmof Hg

Systemic examination::

Per abdomen:::

Inspection..

Shape of abdomen...scaphoid
Umbilicus..inverted,central located
No sinuses or scars on abdomen

Palpation::

No rise in temperature
Tenderness present over upper quadrant  epigastric 
No palpable mass 
No free fluid
Liver palpable
Spleen not palpable

Percussion::

Dull note on right upper quadrant
No fluid thrill
No shifting dullness

Auscultation::

Bowel sound heard

Respiratory system::

B/L symmetrical elliptical
Trachea central
No sinuses ,scars

TVF..equal normal on both sides
Normal vesicular breath sounds heard

Cardio vascular system::
S1s2 heard
JVP not raised
No murmurs

Central nervous system::
Speech normal
Cranial nerves intact
Sensory and motor system: normal
Reflexes.normal

Investigations::

Complete blood picture::

Hemoglobin:12.2gm/dl
Total leucocyte count:5500cels/mm3
Neutrophils:70 %
Lymphocytes:20%
Monocytes:04%
Eosinophils:06%
Basophils:0
Platelet count:2L/mm3

Random blood sugar::102mg/dl

Blood urea 42mg/dl

Serum electrolytes::

Na+:::137
K+:::2.5
Cl-:::102

Serum creatinine::.  1.2mg/dl

Liver function tests::
 
Total bilirubin::0.91 mg/dl
Direct bilirubin::0.18 mg/dl
AST::41IU/L
ALT::43IU/L
ALP::154IU/L
Total protiens::7gm/dl
Albumin::3.8gm/dl
Smear: normocytic normochromic

HIV RAPID TEST :: POSITIVE

Provisional diagnosis::

Gastroenteritis

Treatment::
Iv Fluids
Inj.zofer
Tab.sporolac
Cap radotril
Inj.pan 40
Inj.kcl 1amp in 500ml Ns

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