1601006181 LONG CASE

1601006181 GENERAL MEDICINE LONG CASE

 

This is an 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 patient’s clinical problems with collective current best evidence based inputs. This e-log book reflects my patient centered online portfolio and your valuable inputs on the comments 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 a diagnosis and treatment plan.

A 65 yr old woman hailing from Miryalguda who is a agricultural labourer by occupation came to the hospital on 23. 04 .21 with chief complaints of vomitings since 4 days

HISTORY OF PRESENTING ILLNESS: 

She is a known case of  type -2 diabetes since  10 yrs and hypertension since 1 yr and on medication for both

She was apparently asymptomatic 4 days back; then she developed vomitings which were :

• Sudden in onset
• 2 episodes /day
• Pale in color
• non projectile.
• non bilious.
• non blood stained
• content:- food particles
• immediately after eating food. 
• Associated with constipation and belching since 3 days.

For which she went to miryalguda hospital &was referred to KIMS, Narketpally because of elevated serum creatinine (6.5 mg/dl) and blood urea (171 mg/dl)

She also had pedal edema 

• Insidious in onset 
• Since- 3 days

• -pitting type

•  limited to ankles. (grade-1) 

Negative  history

• No history of fever ,loose stools,pain abdomen abdominal distension , headache, dyspepsia dysphagia
• No h/o heart burn ,hematemesis meleana
• No h/o oliguria , burning micturition  ,dysuria
• No periorbital puffiness
• No h/o Dyspnea, syncope ,palpitation , chest pain

PAST HISTORY

no history of  similar complaints in the past

no history of tb , bronchial asthma, epilepsy, thyroid abnormalities

PAST SURGICAL HISTORY ::

underwent hysterectomy 20years back

FAMILY HISTORY:

• No similar complaints in other family members
• No history of tuberculosis/ bronchial asthma / epilepsy/hypertension

PERSONAL HISTORY

• diet: mixed
• appetite: decreased
• sleep: adequate
• bladder movements : normal& bowel movements decreased 
• no addictions

 MENSTRUAL HISTORY : 

attained menopause 20yrs back

children 3

DRUG HISTORY 

On medication for 

- Diabetes : Inj human actrapid insulin 200-x- 750 since 7 years

- Hypertension for 1 year 

• Clindine trio
• Cilndepine 10mg
• Olmesartam 20 mg
• Chlorthalidone 12.5 mg

- Pedal edema

  Torsemide 10 mg

No known drug allergies

TREATMENT HISTORY

1) IVF - NS

2)iv - lasix

3) iv-zofer 

4) iv - pantop

5) inj- human actrapid insulin HAI

6) pro-cremaffin

GENERAL EXAMINATION: 

• informed consent  obtained 
• conscious, coherent, cooperative
• well oriented to day, date, time & place
• moderately built & nourished

• pallor- no signs of pallor
• icterus - no signs of icterus
• cyanosis - no signs of cyanosis
• clubbing - absent
• koilonychia - absent
• lymadenopathy- absent
• pedal edema - present

       

VITALS

• Afebrile
• Pulse Rate  : -70 bpm

- normal in character

-regular in rhythm

-no radio radial delay  radioofemoraldelay

-normal volume

• BP: 160/80mm hg in left arm in supine position
• RR:  20 cpm
• SPO 2:  98% in room air

SYSTEMIC EXAMINATION

UPPER GIT EXAMINATION

Oral Cavity:

• Lips     normal
• teeth   normal
• gums   normal
• palate normal
• oropharynx normal
• cheek buccal  mucosa normal
• tongue normal
• breath   normal

Abdomen Examination::

Inspection

• shape of abdomen : normal (scaphoid)

• flanks : not full
• no venous prominence
• Umbilicus:  

      -central in position

      -normal (no discharge or hernia seen)

• Skin over abdomen: 

      -no signs of scar ,sinuses ,ulcers

      -no pigmentation, striae

      -no localised swellings

      -no visible pulsations

• movements of abdomen : all quadrants are moving with respiration
• no visible peristalsis
• hernial orifices: free

Palpation

Superficial:

• no local rise of temperature
• no tenderness
• guarding  : absent
• rigidity : absent

Deep Palpation : 

LIVER :

• liver span: normal
• no tenderness

SPLEEN : 

• spleen not palpable

• no rebound tenderness

Percussion 

Tympanic note heard; 

Dull note heard over the upper border of liver and spleen.

• Liver span is normal   

Auscultation 

normal bowel sounds heard

OTHER SYSTEMS

CVS: 

S1 S2 heard 

JVP normal

Respiratory system

Normal vesicular breath sounds heard

CNS- 

Higher Mental functions : intact 

Motor System : Reflexes preserved

Babinskis sign : Flexor response

Sensory system : Cranial nerves intact 

From the history and examination, my provisional diagnosis is Diabetic Ketoacidosis with pedal oedema secondary to hypoalbuminemia caused by diabetic nephropathy.

INVESTIGATIONS: 

Hemogram

CUE

• Pus cells: 3-4
• Epithelial cells: 2-4
• RBCs: nil
• Sugars: nil
• Bile salts and bile pigments: nil 
• Albumin: 2+
• Spot urine Sodium: 153 mEq/L

RFT

• Serum urea: 199 mg/dl
• Serum creatinine: 8.5 mg/dl
• Serum uric acid: 7.8 mg/dl
• Calcium: 10 mg/dl
• Phosphorus: 4.7 mg/dl
• Sodium: 135 mEq/L
• Potassium: 4.2 mEq/L
• Chloride: 106 mEq/L

CXR

USG ABDOMEN

            

ECG

From the investigations, I am of the opinion that it could be Acute Kidney Injury. The cause of her AKI could be-

• Pre renal: Volume depletion from excessive vomitings