1701006131 CASE PRESENTATION

 Long case

COMPLAINTS AND DURATION:

A 79 y/o male was brought to casuality with c/o cough since 1 & half month , fever since 10 days, difficulty in swallowing and h/o Aspiration pneumonia since one month

C/o altered sensorium since 3 days

HOPI 

Patient had H/o left hemiplegia, DM type 2 , Hypertension, Thyroid disorders, and bronchial asthma. 

 Patient was apparently asymptomatic one and half month back when he developed cough insidious in onset and gradually progressive. PRODUCTIVE but patient is not able to spit it out. Fever since 10 days -high grade. O/e Chills and rigors + (38 spikes).

Difficulty in swallowing. N/h/o vomiting, chest pain, loose stools.

PAST HISTORY  

 Patient is a k/c/o Hypertension and type 2 diabetes since past 10years for which he is  on medications I.e tab TELMA AM 40mg po/od.  Tab zoryl mv , po/od

 History of events:-

 • 10 years back , patient developed lesions on his both foot and went to the doctor and found to have diabetes and started on medication.and after 1 year ,with regular check up he was found to be Hypertensive  and started on antihypertensive medication.

 • 7 years back, patient developed head ache at around evening 7pm and followed by vomtings, next day morning onwards patient became drowsy and cannot move his limbs and was taken to the hospital and found to have infarct and started on antiplatelets.

  K/c/o CVA since 7 years. 

   K/c/o seizures disorder since 2 years for which on medications Tab levipil 500mg

  K/c/o hypothyroidism since 5 years on thyronorm 25mcg.

• From 7 years onwards , patient was bedridden with foleys (changed every 15 days) and physiotherapy was done by his attenders daily, but there was no such improvement.

• 20 days back, from March 1st onwards ,patient developed slurring of speech and decreased responsiveness and cough ( mild ) and unable to clear the throat secretions and was taken to the hospital and was treated with antibiotics and patient was brought here for further evaluation.

PERSONAL HISTORY 

Appetite lost, 

Mixed diet

Bowel- constipated, 

Bladder regular 

No known allergies and Addictions.

 i.e non alcoholic and non smoker

Family History-  not any

Treatment history   

 

•Tab TELMA AM 40mg po/od since past   10years

 •Tab zoryl mv , po/od

•Tab levipil 500mg since 2 years

• thyronorm 25mcg. Since5 years

GENERAL EXAMINATION 

O/e PT IS C/C/C

-PALLOR: PRESENT

-NO PEDAL EDEMA, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

VITALS ON ADMISSION 

PR-90 BPM

BP- 140/80MM HG

RR- 22 CPM

SPO2- 98% AT RA

GRBS - 183mg/dl

SYSTEMIC EXAMINATION:

Respiratory :-

 Inspection :  dyspnoea:present

position of trachea: central

No wheezing

Breath sounds : vesicular

CNS

PATIENT WAS C/C/C.

HIGHER MENTAL FUNCTIONS- INTACT

GCS - E3V3M5

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION,

CRANIAL NERVES- cannot be elicited 

 SENSORY SYSTEM- cannot be elicited 

MOTOR SYSTEM: left side

  •TONE- hypotonic 

  •POWER- cannot be elicited both sides

  • B/L REFLEXES: 

BICEPS,  TRICEPS, SUPINATOR,  KNEE  ANKLE - hypotonia

 PLANTARS- hypotonia

CVS

ASCULTATION: S1S2 +,NO MURMURS

P/A

INSPECTION: UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.

AUSCULTATION: no bowel sounds heard

Clinical images :

INVESTIGATIONS 

DIAGNOSIS 

Recurrent CVA with Hypertension, T2 DM, Thyroid disorder, BRONCHIAL ASTHMA, and seizures disorder. 

TREATMENT 

1) TAB ECOSPRIN 150 mg RT/OD

 2) TAB CLOPIDOGREL 75 MG RT/OD 

3) TAB ATORVAS 20 MG RT/OD

4) NEBULISATION - 3% NS ,

                                 MUCUMZY 8th hourly 

5) CHEST PHYSIOTHERAPY.

6) RT FEEDS 100 ML WATER 2nd HRLY

                        50 ML Milk 2nd HRLY.

7) INJ HAP SC | TID / premeal a/l to GRBS 

8) TAB. THYRONORM 25MCG RT/OD

9) TAB. LEVIPiL TOOMG RT/OD

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short case

25 YR OLD MALE WITH CHEST PAIN, VOMITINGS AND SOB 

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A 25 YEAR OLD FEMALE WITH FEVER AND HEADACHE 

Date of admission : 7-2-23

25/M painter by occupation who was apparently asymptomatic 9 years back,

Patient c/o blurring of vision for which he went to local hospital used medication but his blurring of vision(Rt>>Lt) wasn't subsided 

In 2014 patient c/o severe weight loss approximately 10-12 kgs over a duration of 2 months. And having increased apetite, increased frequency of urination with these complaints he went to Local hospital and diagnosed with type 1 diabetes mellitus and since then he was started on Mixtard insulin 28U -x - 24U and since then he is on regular follow up.. His fbs used to be around 200-250 and ppbs around 250-300

Last HbA1c was 11.2 on feb 3rd 

Now since 1 week patient came with c/o fever high grade associated with chills and rigors, Nausea, Vomitings , constipation

And c/o neck pain

No c/o chest pain palpitations , syncopal attacks 

No meningeal signs 

At presentation his grbs is 234  mg/dl with urine for ketones ++ 

Outside 24hr urine proteins 3920mg/day 

On presentation his vitals are 

Afebrile 

BP - 110/80 mmhg

PR - 86bpm

Spo2 - 100 at RA

CVS - S1S2+

RS - normal vesicular breath sounds heard 

On HAI infusion according to Algorithm 1

 

Not a k/c/o HTN / Asthma / CAV / CAD

Personal history :

Sleep: adequate 

Appetite: normal 

Diet: mixed

Bowel and bladder movements: normal 

Addictions: none 

Family history : 

No similar complaints in family 

General examination :

Patient Is conscious, coherent, cooperative moderately built and well nourished 

pallor - Absent 

icterus - Absent

clubbing - Absent

cyanosis - Absent

lymphadenopathy  - Absent

Edema  - Absent

Vitals:

TEMP-96.5 F

PR-82/MIN

RR-14/MIN

BP-110/70MMHG

SPO2-99% AT ROOM AIR

GRBS-197MG%. 

Systemic examination :

CVS - S1S2 present, no murmur

RS - Bilateral air entry present, trachea central in position 

CNS - Higher mental functions intact 

P/A - Soft, non tender

Clinical images with investigations:

   ECG DONE ON PRESENTATION 8-2-23

    REPEAT ECG 8-2-23

    USG ABDOMEN DONE ON 8-2-23

    2D ECHO DONE ON 8-2-23

    BLOOD AND URINE INVESTIGATIONS 

Diagnosis :

DIABETIC KETOACIDOSIS(RESOLVED) WITH OLD INFERIOR WALL MI WITH K/C/O TYPE I DM SINCE 9YRS WITH DIABETIC NEPHROPATHY 

 

Treatment :

* IV FLUIDS NS@75ML/HR

 5% DEXTROSE IF GRBS <= 250MG/DL

* HUMAN ACTRAPID INSULIN INFUSION ( 1ML +39 ML NS) @ 3ML/HR BASED ON GRBS 

* TAB ECOSPRIN GOLD 75/75/10MG PO HS  

* GRBS MONITORING HOURLY

* STRICT I/O CHARTING.

* VITALS MONITORING 2ND HRLY.