1801006019 CASE PRESENTATION

 long case

     A 30 yr old female presented with chief complaints of weakness since one month,

 vomiting since 2 days  and pain abdomen since  3 days.

 HISTORY OF PRESENT ILLNESS:

                         Patient of apparently asymptomatic 1month ago then she developed fever which is sudden in onset , intermittent with no aggrevating and relieving factors associated with  vomiting and diarrhoea.vomitings are non projectile,non bilious,food particles as content ,2-3 times per day for about a week . Diarrhoea which are small volume stools ,watery in consistency,non blood stained,non foul smelling,10 times per day for about a week.she also complaints of lower back pain,localised , insidious onset gradually progressive,dragging type  aggrevates on doing work relieves by rest.No history of trauma to back.  She also complaints of generalized weakness since 1month.                                                                                                                                    Then she visited our hospital and here  diagnosed with anemia with haemoglobin 5.2gm/dl  and advised for admission in the hospital ,but she denied admission and opted for treatment on out patient basis.she is on oral iron supplements since 1 month.                                                                                                                                     At present patient came with  complaints of pain abdomen since 3 days   insidious in onset,diffuse in nature associated with vomiting 3 times per day since day before yesterday containing food particles,non projectile,bilious vomiting not associated with fever.  

DAILY ROUTINE:

                  She is  farmer by occupation.Wakes up at 6AM does her morning routine and drinks a cup of milk daily about 100 ml.Does her breakfast at 9am,packs her lunch  and goes to work.she will have lunch at 1 pm near field.she returns to home at 6 pm and does her household chores and has her dinner by 8 pm ,sleeps at 9pm. 

               But because of these illness now her lifestyle is completely changed she now cannot do any of field work and also she is not able to do her household work too.Her mother who is living with them is doing all her work and helping her.she now used to wakeup at 6 am and does her breakfast and sits for a while but because of backpain she cannot sit for a long time she takes rest. Like this it continuous throughout the day where she sometimes sits,takes rest and has her lunch/dinner.

PAST HISTORY:

              No similar complaints in the past.                                                                                                    Not a k/c/o Hypertension,Diabetes,Asthma, Tuberculosis, Epilepsy,Thyroid abnormalities.

FAMILY HISTORY:

            No significant family history.Her mother has Diabetes and hypothyroidism since 10 years.

PERSONAL EXAMINATION:

          DIET: Mixed 

           Appetite: decreased  

          Bowel and bladder: regular 

          Sleep : Adequate

          No Addictions and No afood or drug allergies

MENSTRUAL HISTORY:

         She attained menarche at 14 years, uses 2 clothes per day (5/30 ) 

Regular cycles, flow is for 5 days , associated with clots and pain.

Marital history:

Age of marriage at 2009 (16)yrs, non consanginous marriage

Obstetric history:

 P2L2 - has 2 children 2 boys , c-section,As per her wish,immunized as per schedule.

1st child- 13 years(2010)(17) born

During 2nd pregnancy she had a transfusion done at 9month for anemia.

2nd child- 9 years(2014)(21) born admitted in NICU (lbw).

Breastfed after 1 day

GENERAL EXAMINATION:

         By taking prior consent.she was examined in a well lit room .

        Patient was consious,coherent,cooperative.he is poorly built and malnourished and well oriented to time place and person.

Pallor: present 

Icterus: Absent 

Cyanosis: Absent 

Koilonychia:Absent

Clubbing: Absent 

Lymphadenopathy: Absent 

Edema :Absent

VITALS:

Pulse rate : 80 bpm,regular rhythm normal volume .

Respiratory Rate: 15Cycles/min 

Blood pressure: 110/80mm hg in right arm examined in sitting position.

Temp:98.6 F

SPO2: 99%@ RA

ABDOMEN EXAMINATION:

Inspection - 

          Umbilicus - inverted
          All quadrants moving equally with respiration
          No scars, sinuses and engorged veins , visible pulsations. 

         

Palpation -  

soft, non-tender

no palpable spleen and liver

Percussion - live dullness is heard at 5th intercoastal space

Auscultation- normal bowel sounds heard. 

CARDIOVASCULAR SYSTEM:

Inspection : 

• Shape of chest- elliptical 
• No engorged veins, scars, visible pulsation 

Palpation :

•  Apex beat can be palpable in 5th inter costal space
• No thrills and parasternal heaves can be felt

Auscultation : 

• S1,S2 are heard
• no murmurs

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

Probable diagnosis:

      Acute Gastritis  with previous history of severe anemia.

Investigations: 

1.Haemogram

2.peripheral smear:

RBC: predominantly Microcytic Hypochromic with few macrocytes,pencil forms.

WBC: Increased counts on smear. 

Platelet: Adequate.

3.Reticulocyte count:1.8%

4.Stool for occult blood: Negative

5. Chest xray

6.ECG 

7.Blood urea: 25mg/dl 

8.ultrasound:

Diagnosis: 

Acute Gastritis resolved with dimorphic anemia with  right sided small kidney.

Treatment:

IV fluids ns 75ml/hr 

INJ pan 40 mg/ IV /od 

INJ Zofer 4mg/IV 

INJ optineuron 1 amp in 500ml  ns/ IV/od 

T.PCM 650 mg   od 

Syp.Sucralfate 10ml/tid 

Syp. Cremaffin citrate 15ml 

INJ vitkofol 1000mcg/IM/od 

T.orofer xt/po/od

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short case

CASE:

 40year old male presented with chief complaints of vomitings and breathlesness on 14-2-23 (since 3 days) .

HISTORY OF PRESENTING ILLNESS:

           Patient was apparrently asymptomatic 3 days ago with a background alcoholic intake without having food.Then he had complaints of vomiting for 3 days ,non bilious  ,food as content, non foul smelling.Patient had taken vomikind injection. patient has the history of feeling breathlessness since 3 days of vomiting(11-2-23).

           Then patient went for consultation in governtment hospital  and was referred to higher centre for which he came to our hospital.

PAST HISTORY:

        No similar complaints in the past

  He was a known case of diabetes since 7 years and was on oral hypoglycemic drugs - Glybenclamide and metformin

         (Irregular medication).He is not taking tablets since 1 week as they are not available.  

  Not a known case of hypertension,asthma,tuberculosis ,epilpsy,coronary artery diseases.

DAILY ROUTINE:

    

       He is a resindent of nagarjuna sagar He owns a car ,works as car driver.He wakes up early morning at 6 '0 clock ,does his morning routine and  eats breakfast at 8:30 am .Then he goes to work at 9 '0 clock and has his lunch around 1-2 pm returns home by 8pm and does his dinner chapathi with curry daily by 9pm and sleeps at 10pm.

PERSONAL HISTORY:

Diet: Mixed 

Appetite: Normal

Bowel and bladder: Regular

Sleep:Adequate 

Addictions:Occasional alcoholic since 15 years  .

No allergies for food or drugs.

FAMILY HISTORY: 

    No significant  family history.

GENERAL EXAMINATION:

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

Hyperpigmented lesions noted over both upper and lower limbs.

Pallor- absent

Icterus- absent

Clubbing-absent

Koilonychia-absent

Lymphadenopathy- absent

Cyanosis- absent

Lymphadenopathy- absent

Cyanosis- absent

Generalized edema - absent

VITALS: 

B.P:150/80 mmhg

P.R:110bpm

R.R: 42cpm

Temp:98.6 F

SPO2: 99%@ RA

SYSTEMIC EXAMINATION:

ABDOMEN EXAMINATION:

Inspection - 

          Umbilicus - inverted

          All quadrants moving equally with respiration
          No scars, sinuses and engorged veins , visible pulsations. 

          Hernial orifices- free.

Palpation -  

soft, non-tender

no palpable spleen and liver

Percussion - resonant note is heard

Auscultation- normal bowel sounds heard. 

CARDIOVASCULAR SYSTEM:

Inspection : 

• Shape of chest- elliptical 
• No engorged veins, scars, visible pulsations
• JVP - no raised jvp

Palpation :

•  Apex beat can be palpable in 5th inter costal space
• No thrills and parasternal heaves can be felt

Auscultation : 

• S1,S2 are heard
• no murmurs

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

PROVISIONAL DIAGNOSIS:

      Diabetic ketoacidosis secondary to in compliance with known case of Type 2Diabetes milletus

Investigations:

Hb: 4.6 g/dl

Sr.creat:4.2

Blood urea :90

HBA1C:7.5

FBS 700mg/dl

TGL:182

HDL 56

LDL 115

VLDL 36

ABG ANALYSIS

pH 7.332

pco2 31.5 mmHg

po2 90.4mmHg

Electrolytes

Na-136mmol/l

K+- 3.5 mmol/l

Cl-96mmol/l

Hco3- 13.6 mmol/l

Urine ketones -positive

TREATMENT:

 On 14-2-23

Inj human act rapid insulin 0.1 IU/kg/hr

Continue iv infusion

Inj PAN 40 mg /IV/OD

Inj Thiamine 200 mg /100 ml NS IV/BD

Inj monocef 1gm/IV /BD

Serum potassium every 6 hrly

Vitals monitoring every 4 hrly and GRBS hrly monitoring 

Inj 10%dextrose 30 ml/hr/IV

On 15-2-23

Same plus GRBS and  vitals monitoring 

On 16-2-23 

GRBS And vitals monitoring .