1801006041 CASE PRESENTATION

 Long case

Presenting complaints:

Patient came to casuality with the cheif complaints of sob since 10 days

Complaints of edema of upper limbs and lower limbs since 6 days

Decreased urine output since 6 days

HOPI:

Patient was apparently asymptomatic 1 year back then he had sob which is intermittent type then he was diagnosed with CKD 1 year back.

10 days back he had sudden onset of sob, which is GRADE IV, orthopnea present, PND associated.

Edema of both upper and lower limbs

Past history:

History of fall from tree10 years ago. Developed low backache and neck pain then 3 years back fever, cough loss of appetite for 2 months diagnosed with tuberculosis and diabetes. ATT for 6 months and on OHA since then

Seasonal SOB with wheeze (since 3 years) on and off and with CKD 1 year ago. 

Past history:

K/c/o TB 3 years back (ATT )

K/c/o DM II 3 years (using Metformin 500mg TID)

K/c/o CKD

GENERAL PHYSICAL EXAMINATION:

Patient is conscious coherent and cooperative

No signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy

VITALS:

TEMPERATURE: afebrile 

PULSE RATE: 102 bpm

RESPIRATORY RATE: 35cpm

BLOOD PRESSURE: 150/90 mm hg

SPO2: 97% @ room air

GRBS: 203 mg/dl

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

S1 AND S2 HEARD.

APEX BEAT @ 6TH INTERCOSTAL SPACE IN ANTERIOR AXILLARY LINE 

P2 NOT PALPABLE 

JVP MILD RAISE

RESPIRATORY SYSTEM:

BILATERAL AIR ENTRY PRESENT 

CENTRAL NERVOUS SYSTEM:

HIGHER MOTOR FUNCTIONS NORMAL

PER ABDOMEN:

SOFT NON Tender

RANDOM BLOOD SUGAR: 125mg/dl

HS

RFT:

S.UREA: 64mg/dl

S. CREATININE: 4.3 mg/dl

S. Na+: 138

S. K+: 3.4

S. Cl-: 104

S. Ca+2: 0.92

HbA1C: 6.5%

2DECHOCARDIOGRAPHY:

MODERATE MR+: MODERATE TR 

MODERATE LV DYSFUNCTION+

DIASTOLIC DYSFUNCTION PRESENT

ULTRASOUND:

USG CHEST: 

E/O FREE FLUID NOTED IN BILATERAL PLEURAL SPACES (RIGHT MORE THAN LEFT) WITH UNDERLYING COLLAPSE

NO E/O ANY CONSOLIDATORY CHANGES IN BILATERAL LUNG FIELDS

IMPRESSION:

BILATERAL PLEURAL EFFUSION (RIGHT MORE THAN LEFT) WITH UNDERLYING COLLAPSE.

USG ABDOMEN AND PELVIS:

MILD TO MODERATE ASCITES

RAISED ECHOGENECITY OF BILATERAL KIDNEYS

RENAL FUNCTION TEST:

UREA: 64

CREATININE: 4.3

Na+ 138

K+ 3.4

Cl-  104

Ca+2.   104

Spot urine protein: 34

Spot urine creatinine: 14.8

Spot urine protein creatinine ratio: 2.29

pH: 7.3

PCO2: 28.0

pO2: 77.4

HCo3: 13.5

Sat O2: 94.7

URINARY ELECTROLYTES:

Urine Na+ 204

K+ 5.1

Cl- 135

FASTING BLOOD SUGAR: 93mg/dl

POST LUNCH BLOOD SUGAR: 152mg/dl

RFT ON 15/03/2023

S. UREA: 140mg/dl

S. CREATININE:5.7 mg/dl

S. Na+:141

S. K+:3.0

S. Cl-:0.90

PROVISIONAL DIAGNOSIS:

HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF:45%) SECONDARY TO CAD

WITH ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (SECONDARY TO DIABETES)

WITH K/C/O DM II SINCE 3 YEARS

WITH OLD PULMONARY KOCHS(3 YEARS AGO)

WITH BILATERAL PLEURAL EFFUSION (RIGHT MORE THAN LEFT)

TREATMENT:

1. FLUID RESTRICTION LESS THAN 1.5 LITRES/DAY

2. SALT RESTRICTION LESS THAN 1.2GM/DAY

3. INJ. LASIX 40 MG IV/BD

4. TAB. MET XL 25 MG PO/OD

5. TAB. CINOD 5 MG PO/OD(IF SBP MORE THAN 110 MM HG)

6. INJ. HUMAN ACTRAPID INSULIN SC/TID (ACCORDING TO SLIDING SCALE)

7. INJ. PAN 40 MG IV/OD

8. INJ. ZOFER 4 MG IV/SOS

9. STRICT I/O CHARTING

10. VITALS MONITORING 

11. TAB. ECOSPRIN AV 75/10 MG PO/

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SHORT CAE

A 49 year old male ,auto driver by occupation came with chief complaints of vomitings and loss of appetite.

History of presenting illness:

Patient was apparently assymptomatic 10 years back and then he developed weaknesses and fever for which he went to local hospital and diagnosed to be having diabetes  for which he was under medication.And after one year he complained to have head ache and was diagnosed with hypertension, for which he used medication for one year and stopped.6 years back he developed weakness of limbs for which he was found to be having low potassium and was treated accordingly.

25 days ago  patient complained of vomitings ( 5 episodes per day ,non bilious and non projectile). Numbness in the left upper limb and lower limb , deviated jaw to the right side , unable to close the left eye for which he was taken to the hospital and diagnosed to have acute ischemic stroke, he was treated accordingly  and discharged.after one week he had vomitings ( 6 episodes) and he was taken to the hospital and they were told that he had high blood sugars and he was treated.

Since 3 days he has 6 - 7 episodes of vomitings per day, and he was admitted at our hospital.

Past history: 

History of diabetes millitus since 10 years ( Tab met Forman -500 mg), 

History of hyperTension since 9 years .

Not a known case of Asthma, tuberculosis,CAD.

Personal history:

Diet:mixed 

Appetite: Normal

Sleep : Normal

Bowel and bladder: regular 

Addictions:smokes ( 10 cigarettes per day)

Alcohol consumption ( 3 times per week)

Family history: 

No relevant family history.

General examination:

Patient is conscious, coherent but not cooperative 

Moderately built and nourished.

Pallor:absent 

Icterus:absent

Clubbing:absent

Cyanosis:absent

Generalised lymphadenopathy:absent

Pedal edema :absent 

Vitals:

Temperature:98.8

Pulse rate:76

Respiratory rate :20

Blood pressure:

Spo2:98

GRBS:

Systemic examination:

Higher mental functions:

MMSE could not be assessed.

Speech : normal 

Behaviour: sluggish 

Gait: patient couldn’t walk.

Reflexes:

CVS: s1 s2 heard no murmurs .

Respiratory: bilateral air entry present , normal vesicular breath sounds heard.

Abdomen:

Soft and non tender ,

No hepatomegaly and spleen is not palpable.

Provisional diagnosis:

Diabetic ketoacidosis secondary to poor glycemic control and non compliance to insulin.

Investigations:

Treatment:

Zofer - 4 mg I/v TID 

Pan I/v TID

Tab ecospirin -75 mg 

Tab Atorvas -90 mg 

Tab clopitab 

Tab pregabe 

Tab sucrolyte 

IV fluids .