1701006199 CASE PRESENTATION

 LONG CASE:

CASE : 

A 75 years old female, home maker by occupation, resident of nalgonda was bought to the casuality with chief complaints of 

• vomitings since 1 day 
• giddiness since 1 day. 

HISTORY OF PRESENTING ILLNESS :

• Patient is a known case of diabetes mellitus and hypertension since 6 years. 

•She was apparently asymptomatic 6 years back. 

• Later she had complaints of headache, generalized weakness for which she was taken to a hospital and there she was diagnosed with diabetes mellitus and hypertension and prescribed on oral medication. From then she was on regular medication. 

• Patient did not use oral hypoglycemics and anti- hypertensives for the past 4 days as she went to relatives house. 

• Patient presented with 2-3 episodes of vomitings, non- bilious and non - projectile followed which she developed giddiness.

•  Contents of the vomitus are food and it is not foul smelling. 
• No history of fever or pain abdomen.
• She was taken to a local hospital where it was found out that her GRBS is 394mg/dL and ketone bodies were positive and referred to our hospital. 

• No history of shortness of breath, chest pain, palpitations. 

PAST HISTORY :

• She is a known case of diabetes mellitus and hypertension since 6 years. 

• No history of Tuberculosis, cardiovascular disease. 
• Surgical history - history of cataract surgery 3years back in one eye and 2 years back in the other eye. 

PERSONAL HISTORY :

• Diet - mixed
• Appetite - normal
• Sleep - adequate 
• Bowel and bladder movements - regular
•  Addictions - chutta smoking for 10years , 3 chutta per day and stopped 5 years back. 
• No allergies 

FAMILY HISTORY : 

• Not significant

MENSTRUAL AND OBSTETRIC HISTORY :

• Attained menopause
• 8 children - 4 boys and 4 girls

DAILY ROUTINE - 

She wakes up early in the morning and has light breakfast and finishes her household chores. She has lunch in the afternoon and takes rest. She enjoys her evenings spending time with her grandchildren. She has an early dinner and  sleeps by 9pm. 

GENERAL EXAMINATION :

• Patient was examined in a well lit room after taking informed consent. 
• She was conscious, coherent and cooperative. Moderately built and we'll nourished.
• Oriented to time, place and person. 

• Pallor - present

• Icterus - absent

• Cyanosis - absent

• Clubbing - absent 

• Generalized lymphadenopathy - absent

• Bilateral pedal edema - absent

VITALS : 

• Pulse - 96 beats per minute, irregularly irregular in rhythm, no radio-radial delay, no radio- femoral delay. 

• Blood pressure - 230/100 mm of hg measured in left arm in supine position 

• Respiratory rate - 17 cycles per minute

• Temperature - Afebrile 

• GRBS - 393 mg/dL

SYSTEMIC EXAMINATION :

CVS - 

• INSPECTION :-  No visible pulsations, no visible apex beat, no visible scars.
• PALPATION :- Apex beat felt
• AUSCULATION :- Mitral area, tricuspid area, pulmonary area, aortic area - S1, S2 heard.

CNS - 

• Higher mental functions - Normal
• Cranial never functions - Normal
• Sensory system - Sensitive
• Motor system       Right       Left

                 POWER- UL     5/5.          5/5

                                  LL.     5/5.         5/5

                  TONE-.   UL.  Normal.  Normal

                                  LL.   Normal.  Normal

                 REFLEXES- 

           Superficial reflexes - Intact

                            Plantar.  Flexion.  Flexion

           Deep tendon reflexes - 

                           Biceps -.  ++.        ++

                          Triceps-.   ++.        ++

                     Supinator.     ++.         ++

                              Knee.     ++.       ++

                          Ankle.       ++.        ++

                 GAIT - Normal

• Cerebellar system - Intact

RS -

• INSPECTION - No tracheal deviation, Chest bilaterally symmetrical. Thoraco abdominal type of respiration. No dilated veins, pulsations, scars or sinuses.
• PALPATION - No tracheal deviation, normal vocal fremitus on both sides.
• PERCUSSION - Resonant in all areas.
• AUSCULATION - Normal vesicular breath sounds, bilateral air entry present.

ABDOMINAL EXAMINATION - 

• INSPECTION - Abdominal distension is present, umbilicus is normal. All quadrants are moving equally with respiration. No visible scars, sinuses, pulsations, engorged veins.
• PALPATION - No local rise of temperature or tenderness in all quadrants. No organomegaly.
• PERCUSSION - No shifting dullness
• AUSCULATION - Bowel sounds and heard, no bruit.

INVESTIGATIONS :

Hemogram - 

• Hemoglobin - 11.3mg/dl
• RBC - 4.47 million/cumm

• TLC -  8900 cells/cumm
• Neutrophils - 80%
• Lymphocytes - 13%
• Eosinophils - 02%
• Monocytes - 05%
• PCV - 33.7 volume%
• MCV - 75.4 fl
• MCH - 25.3 pg
• MCHC - 33.5%
• Platelets -  2.56 lakhs/cumm
• Blood picture - Normocytic normochromic 

Glycosylated hemoglobin - 6.5%

Complete urine examination - 

• Colour - Pale yellow
• Apperance - Clear 
• Reaction - Acidic
• Specific gravity - 1.010
• Albumin - 2+
• Sugar - 4+
• Bile salts and pigments - Nil
• Pus cells - 3-6/hpf
• Epithelial cells - 2-4/hpf
• RBC - Nil
• Casts - Nil

Urine for ketone bodies - 

• POSITIVE on 09-06-22
• NEGATIVE on 11-06-22

Arterial blood gas analysis - 

• pH - 7.44
• pCO2 - 30.6mmHg
• pO2 - 71.4mmHg
• HCO3 - 22.6mmol/L
• O2 saturation - 93.8% 

Electrolytes - 

• Sodium - 139mEq/L (09-06) 

                           134mEq/L (11-06)

                            138mEq/L (12-06)

• Potassium - 3.3mEq/L (09-06)

                               3.6mEq/L (11-06)

                               3.4mEq/L (13-06)

• Chloride - 98mEq/L (09-06)

                             99mEq/L (11-06)

                             99mEq/L (12-06)
Blood urea - 26 mg/dl

Serum creatinine - 1.0 mg/dl

Liver function tests - 

• Total bilirubin - 0.74mg/dl
• Direct bilirubin - 0.18mg/dl
• Aspartate transaminase - 29 IU/L
• Alkaline phosphate - 143 IU/L
• Alanine transaminase - 11IU/L
• Total proteins - 7.7g/dl
• Albumin - 4.1g/dl
• A/G ratio - 1.16

ECG - 

Chest X-ray -

USG - Mild hepatomegaly

DIAGNOSIS - 

Diabetic ketosis with hypertensive urgency

TREATMENT - 

09-06-22

• Intra venous fluids (Normal saline or Ringers lactate ) - 100ml/hr.
• Human ACTRAPID  insulin infusion - 6ml/hr.
• Tab. NICARDIA 20mg PO/stat.
• Inj. OPTINEURON - 1 ampoule in 100ml of Normal saline I.V / OD.
• Inj. ZOFER 4mg I.V/ TID.
• Hourly monitoring of GRBS, pulse, BP, RR and Temperature.

10-06-22

• Intra venous fluids 2 NS - 100ml/he
• Inj. Human ACTRAPID insulin infusion - 6ml/hr
• Inj. OPTINEURON - 1Ampoule in 100ml NS I.V OD
• Tab. TELMA AM 40/5 mg PO OD
• Inj. ZOFER 4mg I.V TID
• Monitoring GRBS, BP, RR, PR.
• Strict input output charting

11-06-22

• Intravenous fluids 2 NS - 75ml/he
• Inj. Human ACTRAPID insulin 10/10/10 and NPH 8/-/8, strict GRBS monitoring
• Inj. OPTINEURON 1 ampoule in NS I.V OD
• Inj. ZOFER 4mg I.V TID
• Tab. CINOD-T (40/10) mg PO OD
• BP 2hrly charting
• Strict input /output charting

12-06-22

• Inj. Human ACTRAPID insulin 12/12/12 and NPH 10/-/10, strict GRBS monitoring
• Inj. OPTINEURON 1 ampoule in NS I.V OD
• Inj. ZOFER 4mg I.V TID
• Tab. CINOD-T (40/10) mg PO OD
• BP 2hrly charting
• Strict input /output charting

13-06-22

• Inj. Human ACTRAPID insulin 12/12/12 and NPH 10/-/10, strict GRBS monitoring
• Inj. OPTINEURON 1 ampoule in NS I.V OD
• Inj. ZOFER 4mg I.V TID
• Tab. CINOD-T (40/10) mg PO OD
• BP 2hrly charting
• Strict input /output charting

14-06-22

•  Inj. Human ACTRAPID insulin 10/10/8 and NPH 8/-/6, strict GRBS monitoring
• Inj. OPTINEURON 1 ampoule in NS I.V OD
• Inj. ZOFER 4mg I.V TID
• Tab. CINOD-T (40/10) mg PO OD
• BP 2hrly charting
• Strict input /output charting

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SHORT CASE:

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

• Fever since 6 days
• Abdominal tightness since 6 days

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 6 days ago when he developed,

• Fever which was low grade and continuous, not associated with chills and rigor. No aggravating factor and relieved with medication given by local rmp doctor. 
• Abdominal tightness which was 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:

• Diet - Mixed.
• Appetite- decreased since 5 days.
• Sleep - adequate.
• Bowel and bladder- regular.
• Addictions: consumes Alcohol and toddy since 15 years.

FAMILY HISTORY:

No similar complaints.

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:

• Pulse - 90 beats per minutee
• Respiratory rate - 20 cycles per minute.
• Temperature - afebrile.
• Blood pressure - 120/80 mmHg.
• Spo2 - 98%.
• GRBS - 110 mg/dl.

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION:

• INSPECTION:

Abdomen shape - distended

Flanks full

Umbilicus - normal

No visible scars, sinuses , striae , engorged veins.

No visible gastric peristalsis.

• PALPATION:

No local rise of temperature.

No tenderness.

Abdomen distended.

Organs not palpable

• PERCUSSION: Fluid thrill is present.

• AUSCULTATION: 

Normal bowel sounds heard.

No bruit.

RESPIRATORY EXAMINATION:

• BAE Present.
• Normal vesicular breath sounds heard.

CVS EXAMINATION: 

• S1 S2 Heard, no murmurs.

CNS EXAMINATION: 

• No neurological deficit.

INVESTIGATIONS:

8/06/2022

 Blood urea - 59 mg/dl

 Serum creatinine - 1.6mg/dl

Serum electrolytes:

• Na - 142 mEq/l
• K- 3.9mEq/l
• Cl - 103 mEq/l

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

Complete urine examination:

• Albumin - 2+
• Pus cells - 4-6
• Epithelial cells - 2 -3.

NS1 ANTIGEN Test - Positive.

IgM and IgG - Negative.

HIV RAPID TEST - Non reactive.

HBsAg Rapid test - Negative.

Anti HCV antibodies - Non reactive.

Ultrasound - Mild splenomegaly .

On right side mild pleural effusion.

Mild ascites.

Grade 2 fatty liver.

Gall bladder wall - edematous.

Hemogram:

On 08-06-22, 

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

On 09-06-22,

Hemoglobin: 14.3gm/dl.

Wbc - 8200 cells/cumm

Neutrophils - 38%

Lymphocytes-51%.

Platelet count - 30,000/cumm.

PCV - 42.0

On 10-06-22,

Hemoglobin- 14 gm/ dl 

Tlc - 5680cells/cumm.

Neutrophils -35%

Lymphocytes - 54%.

Platelet count-84,000/cumm.

On 11-06-22,

Wbc- 4800 cells/cumm.

Neutrophils - 40%

Lymphocytes-48%

Platelet count -60,000cells/cumm

Platelet count -76000cell/cumm.(Same day evening)

On 12-06-22, 

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.

TREATMENT:

12-06-22

• IV infusion NS/RL/DNS continuous at 100ml/hr
• Inj. PAN 40mg IV BD 
• Inj. ZOFER 4mg IV/SOS
• Inj. NEOMOL 1gm IV/SOS
• Tab. PCM 650 mg PO/ SOS
• Inj. OPTINEURON 1 Ampoule in 100ml NS IV/OD over 30mins.

13-06-22

• Oral Fluids
• Tab. DOLO 650mg PO SOS
• Tab. PAN 10mg PO OD
• Tab. DOXYCYCLINE 100mg PO BD
• Tab. ZINCOVIT PO OD
• Vitals monitoring.