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medicine short case

Hall ticket  no 1701006179 

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.

I have 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 diagnosis and treatment plan

A 75 YEAR OLD FEMALE WITH DKA AND HTN

A 75 Year old female, who is  farmer by occupation, resident of Nalgonda , came to the hospital on 9/6/22  with 

CHIEF COMPLAINTS:

1. Nausea and vomitings since morning

2. Giddiness since morning

HISTORY OF PRESENTING ILLNESS:

Time line:


Patient was apparently asymptomatic 6 years back then she developed  Generalized weakness, headache for which she visited the hospital and was diagnosed with Diabetes and Hypertension  for which medication was prescribed . Since 4 days she didn't take her medications as she went to visit her relatives. 

She came to the hospital with complaints  of 2-3 episodes of vomiting, non-bilious, non-projectile, followed by giddiness. 

She was taken to a local hospital primary, where she was found to have GRBS-394 mg/dl and ketone bodies +ve. 

No h/o Chest pain, palpitations, syncopial attacks.

No h/o Shortness of Breath.

No h/o Pain abdomen, burning micturition or loose stools.

PAST HISTORY 

No history of similar complaints in the past. 

Patient is a known case of HTN and DM and is on prescribed medications. 

H/o Cataract surgery in right eye 3 years ago and in left eye 2 years ago.

 Not a known case of  Bronchial asthma, Epilepsy, TB. 

PERSONAL HISTORY

DIET - Mixed

APPETITE- Normal

SLEEP - Adequate

BOWEL AND BLADDER- Regular

ADDICTIONS - No addictions

No known allergies

Family history 

Insignificant

GENERAL EXAMINATION

Patient was examined in a well lit room after taking informed consent.

She is conscious, coherent and cooperative; moderately built and well nourished.

No Pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.





VITALS 

BLOOD PRESSURE: 230/100 mmHg

GRBS: 393mg/dl 

PULSE PRESSURE: 90 Bpm

RESPIRATORY RATE: 18cpm

TEMPERATURE: Aferbile

SpO2: 97% on Room air

SYSTEMIC EXAMINATION

1. RESPIRATORY SYSTEM: Normal Vesicular breath sounds heard.

2. CARDIOVASCULAR SYSTEM: S1 and S2 Heard, no murmurs.

3. CENTRAL NERVOUS SYSTEM: No focal neurological deficits.

4. PER ABDOMEN: Soft, non- tender, no abdominal mass.


INVESTIGATIONS 

 RBS - 164 mg/dl

BLOOD UREA - 26 mg/dl8

 SERUM CREATININE- 1.0 mg/dl

 URINE EXAMINATION 

  • Albumin: ++
  • Sugar: ++++
  • Pus cells-3 to 6
  • Epithelial cells -2 to 4

URINE FOR KETONE BODIES - 

On 9/06/2022

Positive 

On 11/06/2022

Negative 

HEMOGRAM 

  • Hemoglobin: 11.3mg/dl 

LIVER FUNCTION TESTS:

  • Total bilirubin: 0.74mg/dl
  • Direct bilirubin: 0.18mg/dl
  • Aspartate transaminase: 29IU/L
  • Alkaline phosphate: 143IU/L
  • Alanine transaminase: 11IU/L
  • Total proteins: 7.7g/dl
  • Albumin: 4.1g/dl
  • A/G ratio: 1.16   


ABG Analysis

  • pH     : 7.44
  • pCO2 : 30.6mmHg
  • pO2.  :71.4mmHg
  • HCO3:22.6mmol/L
  • O2sat:93.8%

    Seronegative for HIV, HEPATITIS B and C

     USG- Mild hepatomegaly

     ECG:


PROVISIONAL DIAGNOSIS

Diabetic Ketosis with Hypertensive Urgency

TREATMENT

9/06/2022

  1. Intravenous fluids normal saline/ ringer lactate @100ml/hr
  2. Injection Human actrapid insulin I.V infusion @6ml/hr
  3. Inj. OPTINEURON 1 ampoule in 100ml NS (IV)/ OD
  4. Inj. ZOFER 4mg IV/ TID
  5. Tab. NICARDIA 20mg PO/ STAT
  6. Monitor GRBS, PR, BP, RR CHARTING hourly
  7. Strict input output charting


10/06/2022

  1. Intravenous fluids NS 2 @ 100ML/hr
  2. Injection Human actrapid insulin I.V infusion @6ml/hr
  3. Inj. OPTINEURON 1 ampoule in 100ml NS (IV)/ OD
  4. Inj. ZOFER 4mg IV/ TID
  5. Tab TELMA- AM (40/5) mg PO OD
  6. MONITORING GRBS,BP,PR, RR CHARTING
  7. Strict Input output charting


11/06/2022

  1. Intravenous fluids NS 2 @ 75mL/hr
  2. Injection Human actrapid insuin 10/10/10 and  NPH 8/-/8 ,strict GRBS monitoring
  3. Inj. OPTINEURON 1 ampoule in  NS (IV)/ OD
  4. Inj. ZOFER 4mg IV/ TID
  5. Tab CINOD-T (40/10) mg PO OD
  6. BP 2nd hourly charting
  7. Strict input/output charting


12/06/2022

  1. Injection Human actrapid insulin 12/12/12 and NPH 10/-/10, Strict GRBS monitoring 
  2. Inj. OPTINEURON 1 ampoule in  NS (IV)/ OD
  3. Inj. ZOFER 4mg IV/ TID
  4. Tab CINOD-T (40/10) mg PO OD
  5.  BP 2nd hourly charting
  6. Strict input/output charting


13/06/2022


  1. Injection Human actrapid insulin 12/12/12 and NPH 10/-/10, Strict GRBS monitoring 
  2. Inj. OPTINEURON 1 ampoule in  NS (IV)/ OD
  3. Inj. ZOFER 4mg IV/ TID
  4. Tab CINOD-T (40/10) mg PO OD
  5.  BP 2nd hourly charting
  6. Strict input/output charting





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