1801006049 CASE PRESENTATION
LONG CASE
A 60 year old man resident of Sangaram, Nalgonda who was a farmer by occpation came with chief complaints of both lower limbs edema since 10days, upper limbs edema since 5days and vomitings, loose stools and decreased urine output
History of presenting illness:
Patient was apparently asymptomatic 10days back then he developed bilateral pedal edema which was insidious in onset and gradually progressive
He also developed upper limbs edema since 5days
H/o 6episodes of vomitings which are non bilious non projectile and food as content and 4episodes of loose watery stools
Sequence of events:
18years ago patient’s sister’s death occurred which disturbed the patient emotionally and he did not have food for 2-3days.
At that time patient has involuntary passage of stool and was taken to a hospital and was diagnosed with diabetes mellitus and was on kept on OHA
8years ago he met with an accident and has injured his right shoulder for which he was given surgical treatment
4years ago while he was cutting trees, a log has fell on his right lower limb and got his right knee and was treated with surgery
2years ago he developed altered sensorium and had high sugars then he was diagnosed to have DKA and was treated accordingly
4months back he complained of pedal edema and went to a hospital in Nalgonda and the edema got resolved in a week but then he developed vomitings for 3days which are non bilious and non projectile and then had altered sensorium and was brought to our hospital and was found out to be having hyponatremia and hypokalemia which were corrected with 3%NS and later with in 1-2 days patient became normal
10days ago patient developed pedal edema for which he went to a hospital in nalgonda again and was treated for 4days and on 10/3/23 he suddenly started having vomitings(6 episodes of vomitings in 2 days) and loose watery diarrhoea (4 episodes) later on his sensorium deteriorated and has decreased urine output and was brought to our hospital on sunday night(12/3/23).
Past history:
Patient is a known case of diabetis mellitus since 10years and is on Tab. Glimipride 1mg before breakfast and Tab. Metformin 500 mg after breakfast.
He is also a known case of hypertension since 4years and is on medication (Tab. Telma H(TELMISARTAN 40 mg+ hydrochlorthiazide 12.5mg) in morning and Tab. Cilacar 10mg at night)
He has no Tuberculosis, Asthma, Epilepsy, Coronary artery disease
Personal history:
He takes mixed diet, has decreased appetite, sleep is adequate, bowel movements are regular.
Addictions: He was a chronic alcoholic and chronic smoker but stopped taking 20years ago
Daily routine:
He wakes up at 6 am in the morning and does his morning activities will have breakfast by 8 am and stays at home (he used to go to work in fields and sometimes cutting trees) and will have his lunch by 1 pm which consists of rice and curry and comes to the home by 5 or 6 pm when he used to work and will have dinner by 8pm and goes to bed by 10pm.
Family history
No member of the family has similar complaints
General examination:
Patient is conscious, coherant, cooperative. He is moderately built and moderatly nourished.
Mild pallor, no icterus ,clubbing, cyanosis and generalised lymphadenopathy
Bilateral pedal edema
Vitals
Temperature: Afebrile
Pulse rate: 86bpm
Respiratory rate: 18cpm
Blood pressure:140/80mmHg
Systemic examination:
Per abdomen:
On Inspection abdomen is not distended, umbilcus is present centrally and inverted. Scars are present. There are no engorged veins. All 9 regions of abdomen are equally moving with respiration. Hernial orifices are free
On palpation abdomen is soft , non tender and no organomegaly. All inspectory findings are confirmed.
On percussion: no shifting dullness, no fluid thrill
On auscultation: normal bowel sounds are heard.
Respiratory system:
On Inspection:
Shape of the chest is elliptical
Bilaterally symmetrical movements on respiration
On Palpation:
Trachea is central
Expansion of chest is symmetrical.
On Auscultation:
B/L air entry present . Normal vesicular breath sounds heard
Cardiovascular system
On Inspection :
Shape of chest is elliptical
No engorged veins, scars, visible pulsations
No raised JVP.
On Palpation : Apex beat can be palpable in 5th inter costal space medial to mid clavicular line.
On Auscultation : S1,S2 are heard ,no murmurs.
Central nervous system:
Conscious, oriented to time place and person.
GCS on the day of admission was E4 V5 M6
speech : normal
Behaviour : normal
Memory : Immediate memory is slightly impaired recent and remote memory are normal
No hallucinations or delusions
Cranial nerve examination:
CN1: Normal
CN2: normal
CN3,4,6: normal
CN5: sensory intact
CN7:no abnormality noted
CN8: No abnormality noted.
CN9,10: palatal movements present and equal.
CN11,12: normal.
Motor system examination
Bulk: normal
Tone: normal
Power:
Rightside Left side
Upper limb 5/5 5/5
Lower limb 5/5 5/5
Superficial reflexes are present
Deep tendon reflexes
Right Left
Biceps 2 2
Triceps 2 2
Supinator 2 2
Knee 2 2
Ankle 1 1
Sensory system: normal
Cerebellar signs: no
Investigations
Haemogram
Hb 9.5gm/dl
Total count 11500cell/cumm
Neutrophils 91%
Lymphocytes 6%
Pcv 24.7vol%
Mcv 76 fl
MCHC 38.5%
RBC 3.25 millions/cumm
On 16/03/23
Hb 10.2gm/dl
Total count 13500cell/cumm
Neutrophils 80%
Lymphocytes 15%
Pcv 27.1vol%
Mcv 77fl
MCHC 37.6
RBC 3.52millions/cumm
Serum electrolytes
On 12/03/23
Sodium - 118
Potassium -3.0
Chloride -72
On 13/03/23
Sodium - 120
Potassium -3.0
Chloride -75
On 14/03/23
Sodium - 119
Potassium -2.7
Chloride -78
On 15/03/23
Sodium-115
Potassium-4.0
Chloride-80
On 16/03/23
Sodium- 116
Potassium-4
Chloride-80
ABG
pH 7.5
Pco2 28.9
Po2 88.9
16/03/23
pH 7.49
Pco2 27.2
Po2 85.2
HCO3 21
Serum creatinine
1.5mg/dl (0.9-1.3)
Blood urea
42mg/dl (12-42)
On 16/03/23
Blood urea 51mg/dl
Urinary electrolytes
Sodium - 152mmol/l
Potassium -25mmol/l
Chloride -119mmol/l
Fasting blood sugars
161mg/dl
Post lunch blood sugar
219mg/dl
Glycated Haemoglobin
HbA1c 7.2%
Serum Osmolality
263mOsm/kg (275-295)
Serum MAGNESIUM
2.0mg/dl (1.8-2.9)
Serum PHOSPHORUS
2.9mg/dl (2.5-4.5)
Serum CALCIUM
9.0mg/dl (8.6-10.2)
LFT
ALP 212 (56-119)
Total proteins 4.8 (6.4-8.3)
Albumin 2.6(3.2-4.6)
Complete urine examination
Albumin +++
Sugar ++
Chest XRay
ECG
Ultrasound
Diagnosis
Hypoosmolar hypervolemic hyponatremia acute kidney injury with Diabetes mellitus and Hypertension
Treatment:
1. FLUID RESTRICTION
2. INJ. KCL 20mEq IN 100ML NS @ 20ml/hr
3. TAB. METFORMIN 500 MG PO/BD
4. TAB. GLIMIPERIDE 1MG PO/BD
5. TAB. TELMA 40 MG PO/BD
6. TAB. MET XL 25 MG PO/BD
7. VITALS MONITORING
8. GRBS MONITORING.
9.TAB. CILINDIPINE 10MG PO/BD
10. INPUT OUTPUT CHARTING
11. SYRUP. POTCHLOR 15ML PO/TIDVIN 1 GLASS OF WATER
12. INJ. ZOFER 4 MG IV/SOS
13. INJ. PAN 40 MG IV/OD
14. TAB. ALDACTONE 50 MG PO/OD
15. TAB. GLICLAZIDE 40 MG PO/OD
A 49year old man autodriver by occupation from AP Lingotam came with complaints of vomitings from 2days
History of presenting illness:
He was apparently asymptomatic 10years ago then went to a hospital for fever and generalised weakness and was diagnosed with diabetes and was started on oral hypoglycaemic agents(Metformin).
6years ago, he had history of vomitings and found to have low potassium levels for which he was accordingly managed.
2 days ago around 3am he started to have vomitings, 8-9 episodes non bilious, non projectile, with food as content. He went to a local hospital and found his sugar levels were high and was referred to our hospital.
Past history:
H/o Diabetes mellitus since 10 years and is on regular medication (Tab.Metformin 500mg)
No H/o CAD, Tuberculosis, epilepsy, asthma
Family history:
No member of family has similar complaints
Personal history:
Appetite: Normal
Diet: Mixed
Bowel and bladder movements:regular
Sleep: adequate
Addictions: He consumes alcohol 90ml occasional and smokes beedi 1pack daily
Daily routine:
He waked up at 6am in the morning and goes to work (auto driving) at around 8am. He takes his breakfast at 10am and does his work. He usually have his lunch at 1pm and continues with his work and then comes home at around 7pm eats dinner at 9pm and sleeps at 10pm.
General Examination:
Patient is conscious, coherent and cooperative
He is moderately built and nourished.
No Pallor, Icterus, Cyanosis, Clubbing, Generalised lymphadenopathy, B/l pedal edema.
Vitals:
Temperature: Afebrile
Pulse rate: 100bpm
Blood pressure:160/90mmHg
Respiratory rate:18cpm
GRBS: 416mg/dl on day of admission
Systemic examination:
Respiratory system:
Inspection- elliptical shape
Bilaterally symmetrical movements on respiration
B/l air entry present, normal vesicular breath sounds heard
Cardiovascular system:
Apex beat left 5th intercostal space
S1, S2 heart sounds heard, no murmurs heard
Central nervous system:
He is conscious
Speech: normal
Tone:
upper limbs:normal
Lower limbs:normal
Reflexes:
Superficial reflexes are present
Deep tendon reflexes:
Right side: Left side:
Biceps: 2 2
Triceps: 2 2
Supinator:2 2
Knee: 2 2
Ankle: 1 1
Per abdomen: flat, no distension
Soft, non tender
Liver: not enlarged
Spleen: non palpable
Provisional diagnosis:
Diabetic ketoacidosis
Investigations:
Hb: 12.3gm/dl
RBC:6.05 mil/cumm
TLC:11,300 cell/cumm
Platelet count:3.24lakh
ABG:
pH 7.14
Pco2 46mmHg
Po2 125mmHg
HCO3 15mmol/L
Urine examination:
Sugars: ++++
Ketones:+
Treatment:
IV fluids NS@125ml/hr
Inj.NPH SC BD
Inj.HAI SC TID
Inj.OPTINEURON 1amp in 100ml NS IV OD
Inj.ZOFER 4mg IV
Inj.NEOMOL 1gm IV
Tab.ECOSPRIN 150mg OD
Tab.CLOPITAB 75mg OD
Tab.ATORVASTATIN 40mg OD
Tab.TELMA 40mg OD
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