75 year old female with diabetic ketosis and hypertensive urgency

 FINAL MBBS PRATICAL EXAMINATION: LONG CASE

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

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.