FINAL PRACTICAL EXAM LONG CASE

 This is an online E-Log book to discuss our patient's de-identified 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 these patient's clinical problems with collective current best evidence-based inputs. This E-log also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are 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.

ROLL NO: 1701006162

A 75 years old female, resident of nalgonda, came to casualty on 9th June 2022 with 

CHIEF COMPLAINTS:

Vomiting and giddiness since morning.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 6 years back then she had complaints of headache and generalised weakness, for which she visited hospital was diagnosed with type 2 diabetic mellitus and hypertension. She used medication for the same.( Glimepiride 1mg and metformin 500mg)

On 5th June 2022, patient went to her relatives and there she did not use oral hypoglycemic agents and anti hypertensive for 4 days, due to which on 9th June 2022 she had 2-3 episodes of vomiting, non bilious and non projectile, contains food particles  followed by giddiness. She was taken to local hospital, where she found her GRBS was  394mg/dL and her urine sample was positive for ketone bodies. (Referred to our hospital)
No complaints of shortness of breath, chest pain, palpitations, syncopal attacks.
No complaints of burning micturition, loose stools, pain abdomen.

PAST HISTORY:

No similar complaints in past.

Not a known case of tuberculosis, asthma, epilepsy and coronary artery disease.

History of cataract surgery 3 years ago in right eye and 2 years ago in left eye.

PERSONAL HISTORY:

  1. Diet:mixed
  2. Appetite: normal
  3. Sleep: adequate
  4. Bowel and bladder movements: regular
  5. Addictions:Consumes alcohol occasionally (90mL), smoked chutta for 10years, stopped 5 years back
  6. No history of 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, cyanosis, clubbing, lymphadenopathy, edema.

VITALS: on 9/06/2022
  1. Temperature: 99°F
  2. Respiratory rate: 18cpm
  3. Pulse rate: 90bpm regular volume and character , no radio radial and radiofemoral delay.
  4. Blood pressure: 230/100 mmHg
  5. SpO2: 97% on Room air
  6. GRBS: 393 mg/dL 







SYSTEMIC EXAMINATION:

  1. Respiratory system: Normal vesicular breath sounds heard.
  2. CVS: S1 and S2 heard, no murmurs.
  3. CNS: no focal neural deficit
  4. Per Abdomen: soft, non tender, no abdominal mass.

INVESTIGATIONS:

  1. Random blood sugar: 164mg/dl
  2. Blood Urea: 26mg/fl
  3. Serum Creatinine: 1.0 mg/dl
  4. Electrolytes: Sodium     - 139mEq/L                                 Potassium- 3.3mEq/L.                                 Chloride   -98mEq/L
  5. Complete urine examination:
    • Albumin: ++
    • Sugar: ++++
    • Pus cells: 3-6 /HPF
    • Epithelial cells: 2-4 / HPF
    • Red blood cell: NIL
    • Casts: NIL
     6. BLOOD PICTURE
    • Hemoglobin: 11.3mg/dl
    • Total leucocyte count: 8900cell/cumm
    • Neutrophils: 80
    • Lymphocytes:13
    • Eosinophils:02
    • Monocytes:05
    • Platelets: 2.67 lakhs/cumm
    • RBC: 4.47million/cumm
    7. 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
      8.  Arterial blood gas:
    • pH     : 7.44
    • pCO2 : 30.6mmHg
    • pO2.  :71.4mmHg
    • HCO3:22.6mmol/L
    • O2sat:93.8%
     9. Urine KETONE BODIES POSITIVE 
   10. Glycated Hemoglobin: 6.5%
   11. Seronegative for HIV, HEPATITIS B and           C
   12. 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
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
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. MONITORING BP 2nd hourly charting













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