75 year old female with diabetic ketosis and hypertensive urgency
FINAL MBBS PRATICAL EXAMINATION: LONG CASE
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M Tharun Kumar
Hall ticket no: 1701006115
I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
CASE REPORT:
75year old female who is a housewife , resident of miryalaguda was brought to the casuality with
CHIEF COMPLIANTS
Giddiness since 1day
Vomiting since 1day .
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 6years back and was able to perform her regular activities without any difficulty then she experienced headache and generalised weakness for which she consulted a local medical practitioner and was diagnosed with TYPE 2 DIABETES MELLITUS and HYPERTENSION. She was prescribed with medicines (oral hypoglycemic Agents and antihypertensive drugs) and was on regular medication.
4 days back she went to her relatives house and has a H/O no intake of antihypertensives and oral hypoglycemic drugs due to which she developed vomitings and giddiness.
VOMITINGS -
Sudden in onset
Non bilious , non projectile , non foul smelling.
Food particles as content .
Not associated with fever , pain abdomen and loose stools.
She was taken to the local hospital and was found to have General random blood sugar (GRBS) 394mg/dl.
And also urinary ketone bodies were positive .
No H/O chest pain , palpitations , syncopal attacks.
No H/O shortness of breath , burning micturition .
PAST HISTORY :
No similar compliants in the past.
Not a known case of tuberculosis , Coronary artery disease, epilepsy , asthma .
Surgical history : H/O cataract surgery 3 back in right eye and 2 yrs back in left eye .
PERSONAL HISTORY:
Mixed diet
Appetite normal
Sleep adequate
Bowel and bladder regular
Addictions : chutta smoking for 10years , 3 chutta per day and stopped 5 years back.
Intake of alcohol and toddy on social gatherings.
FAMILY HISTORY :
Not significant.
No H/O Tuberculosis, epilepsy, asthma .
GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative ,
well oriented to time, place , person.
Moderately built and nourished.
Patient was examined in supine position in a well lighted room after taking consent.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Edema - absent
VITALS :
Temperature - afebrile
Pulse rate - 90 beats per minute.
Respiratory rate - 20 cycles per minute
Blood pressure - 230/110mmHg at the time of presentation(around 7pm) 09/06/2022.
On 10 /06/2022
Blood pressure - 150/100mmHg.
GRBS - 394mg/dl ( at presentation)
On 10/06/22 - 226mg/dl .
11/06/2022
Blood pressure - 180/100 mm Hg
Pulse rate - 72 beats per minute
SYSTEMIC EXAMINATION ::
GIT
INSPECTION :
Abdomen - distended
Umbilicus - transverse slit like
Movements - all quadrants are equally moving with respiration
No scars and sinuses
No visible peristalsis
No engorged veins.
PALPATION:
No local rise in temperature and no tenderness in all quadrants
LIVER: no hepatomegly
SPLEEN- not enlarged
KIDNEYS - bimanual palpable kidneys
PERCUSSION :
no shifting dullness
AUSCULTATION :
Bowel sounds are heard and are normal
No bruit.
Other system examination :
Respiratory system:
Inspection:
No tracheal deviation
Chest bilaterally symmetrical
Type of respiration: thoraco abdominal.
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.
Palpation:
No tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Tenderness over chestwall- absent.
Vocal fremitus- normal on both sides.
Percussion:
Supraclavicular
Infraclavicular.
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapular
Interscapular
Right side and left side- resonant in above areas.
Auscultation:
Normal Vesicular breath sounds
Bilateral Airway entry - present.
Cardiovascular system:
Inspection : no visible pulsation , no visible apex beat , no visible scars.
Palpation: all pulses felt , apex beat felt.
Percussion: heart borders normal.
Auscultation:
Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.
Central Nervous system:
Higher motor functions- Normal
Speech: Normal
Cranial nerve functions - Intact.
Sensory system- sensitive to pain, touch , vibration and temperature.
Motor system Right. Left
Power- UL 5/5 5/5
LL 5/5 5/5
Neck Normal
Trunk muscles Normal
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
DIAGNOSIS :
HYPERGLYCEMIA AND HYPERTENSIVE URGENCY (2⁰ to non compliance to medication) .
INVESTIGATIONS :
Urinary ketone bodies - positive .
ECG :
2D ECHO Report :
PROVISIONAL DIAGNOSIS :
DIABETIC KETOSIS WITH HYPERTENSIVE URGENCY.
TREATMENT :
1. I.V fluids (normal saline,ringer lactate) at 100ml/hr.
2. Inj. Human act rapid insulin i.v. infusion at 6ml/hr.
3. Inj.Zofer 4mg i.v. /TID
4. Optineuron 1 ampule in 1000ml NS i.v. OD
5. Nicardia 20mg PO stat.
6. Hourly GRBS , B.P. , vitals monitoring.
7 . Strict I/O charting.
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