9th semester
Roll no. 1701006121
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.
CASE :
75 years old female home maker by occupation, resident of dhamarcherla was bought to the casuality with chief complaints of vomitings and giddiness since 1 day.
HISTORY OF PRESENTING ILLNESS :
•Patient is a known case of diabetes mellitus and hypertension since 6 years.
•She was apparently asymptomatic 6 years back.
Later she had complaints of headache, generalized weakness for which she was taken to a hospital and there she was diagnosed with diabetes mellitus and hypertension and prescribed on oral medication. From then she was on regular medication.
• Patient did not use oral hypoglycemics and anti- hypertensives for the past 4 days as she went to relatives house.
• Patient presented with 2-3 episodes of vomitings, non- bilious and non - projectile followed which she developed giddiness. Contents of the vomitus are food and it is not foul smelling. No history of fever or pain abdomen.She was taken to a local hospital where it was found out that her GRBS is 394mg/dL and ketone bodies were positive and referred to our hospital.
• No history of shortness of breath, chest pain, palpitations.
PAST HISTORY :
She is a known case of diabetes mellitus and hypertension since 6 years.
No history of Tuberculosis, cardiovascular disease.
Surgical history - history of cataract surgery 3years back in one eye and 2 years back in the other eye.
PERSONAL HISTORY :
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and bladder movements - regular
Addictions - chutta smoking for 10years , 3 chutta per day and stopped 5 years back.
No allergies
FAMILY HISTORY :
Not significant
MENSTRUAL AND OBSTETRIC HISTORY :
Attained menopause
8 children - 4 boys and 4 girls
GENERAL EXAMINATION :
Patient was examined in a well lit room after taking informed consent.
She was conscious, coherent and cooperative.
Oriented to time, place and person.
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Generalized lymphadenopathy - absent
Bilateral pedal edema - absent
VITALS :
Pulse - 96 beats per minute, irregularly irregular in rhythm, no radio-radial delay, no radio- femoral delay.
Blood pressure - 230/100 mm of hg measured in left arm in supine position
Respiratory rate - 17 cycles per minute
Temperature - Afebrile
GRBS - 393 mg/dL
SYSTEMIC EXAMINATION :
CVS :
Inspection : no visible pulsation , no visible apex beat , no visible scars.
Palpation: apex beat felt.
Auscultation:
Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.
CNS :
Higher mental functions - Normal
Cranial nerve functions - Normal
Sensory system - Sensitive
Motor system Right. Left
Power- UL 5/5 5/5
LL 5/5 5/5
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
RS :
Inspection:
No tracheal deviation
Chest bilaterally symmetrical
Type of respiration: thoraco abdominal.
No dilated veins,pulsations,scars, sinuses.
Palpation:
No tracheal deviation
Vocal fremitus- normal on both sides.
Percussion:
Resonant in all areas
Auscultation:
Normal Vesicular breath sounds
Bilateral Airway entry - present.
ABDOMINAL EXAMINATION :
INSPECTION :
Abdomen - distension present
Umbilicus - normal
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
No organomegaly
PERCUSSION :
no shifting dullness
AUSCULTATION :
Bowel sounds are heard and are normal
No bruit.
INVESTIGATIONS :
Haemogram :
Hb - 11.3 g/dL
TLC - 8100
Platelets - 2.67 lakhs
Normocytic normochromic anaemia
Complete urine examination :
Albumin - 2+
Sugar - 4+
Pus cells - 3-6
Epithelial cells - 2-4
RBC - nil
Casts - nil
Urine for ketone bodies - positive
Arterial blood gas analysis :
PH - 7.44
Co2 - 30.6
O2- 71.4
Hco3 - 22.6
O2 Saturation - 94%
Electrolytes :
Sodium - 133 mEq/dL
Potassium - 4.2 mEq/ dL
Chloride - 102 mEq/ dL
Blood urea - 26mg/dL
Serum creatinine - 1mg/dL
Ecg :
2D echo :
DIAGNOSIS :
Diabetic ketosis with hypertensive urgency
TREATMENT :
• Intra venous fluids( NS, RL) - 100ml /hr
• HUMAN ACTRAPID insulin infusion -6ml/hr
• Tab. NICARDIA 20mg PO/stat
• Inj. OPTINEURON -1 ampoule in 100ml of NS IV/OD
• Inj. ZOFER 4mg IV / TID
• Hourly monitoring of grbs, pulse, bp, rr, and temperature.
Comments
Post a Comment