FINAL EXAMINATION LONG CASE

A 75 YEAR OLD FEMALE WITH DKA AND HTN

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Name : SOWJANYA REDDY PALAKURTHY

Hall Ticket Number : 1701006175

Roll no. - 130 

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A 75 Year old female, farmer by occupation, resident of Nalgonda , came to casualty on 9th June 2022 with chief  complaints of-

CHIEF COMPLAINTS:

1. Nausea and vomitings since morning

2. Giddiness since morning

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 6 years ago then she developed symptoms such a Generalized weakness, headache for which she went to hospital and was diagnosed with Diabetes and Hypertension. She was prescribed medicines for it. 

Since 4 days she missed her medications as she went to visit her relatives. 

On presentation( 9/06/2022),

she complained 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.

DAILY ROUTINE

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 CAD, Bronchial asthma, Epilepsy, TB.

No h/o any previous surgeries.

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 icterus, clubbing, cyanosis, lymphadenopathy, edema.

Pallor - present

VITALS on 9/06/2022

1. BLOOD PRESSURE: 230/100 mmHg
2. PULSE PRESSURE: 90 Bpm
3. RESPIRATORY RATE: 18cpm
4. TEMPERATURE: Aferbile
5. SpO2: 97% on Room air
6. GRBS: 393mg/dl 

SYSTEMIC EXAMINATION

1. RESPIRATORY SYSTEM 
INSPECTION - No tracheal deviation, Chest bilaterally symmetrical. Thoraco abdominal type of respiration. No dilated veins, pulsations, scars or sinuses.
PALPATION - No tracheal deviation, normal vocal fremitus on both sides.
PERCUSSION - Resonant in all areas.
AUSCULATION - Normal vesicular breath sounds, bilateral air entry present.

2. CARDIOVASCULAR SYSTEM
INSPECTION :-  No visible pulsations, no visible apex beat, no visible scars.
PALPATION :- Apex beat felt
AUSCULATION :- Mitral area, tricuspid area, pulmonary area, aortic area - S1, S2 heard.

3. ABDOMINAL EXAMINATION - 
INSPECTION - Abdominal distension is present, umbilicus is normal. All quadrants are moving equally with respiration. No visible scars, sinuses, pulsations, engorged veins.
PALPATION - No local rise of temperature or tenderness in all quadrants. No organomegaly.
PERCUSSION - No shifting dullness
AUSCULATION - Bowel sounds and heard, no bruit.

4. CNS - 

• Higher mental functions - Normal
• Cranial never 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

INVESTIGATIONS 

1. RANDOM BLOOD SUGAR - 164 mg/dl

2. GLYCATED HEMOGLOBIN (HB1AC)- 6.5%

3. BLOOD UREA - 26 mg/dl

4. SERUM CREATININE- 1.0 mg/dl

5. SERUM ELECTROLYTES- 

On 9/06/2022

• Sodium - 139mEq/L
• Potassium - 3.3mEq/L
• Chloride - 98mEq/L

On 11/06/2022

• Sodium - 134mEq/L
• Potassium - 3.6mEq/L
• Chloride - 99mEq/L

On 12/06/2022

• Sodium - 138mEq/L
• Potassium- 3.4mEq/L
• Chloride- 99mEq/L

6. COMPLETE URINE EXAMINATION 

On 9/06/2022

• Colour: Pale Yellow
• Appearance: Clear
• Reaction: Acidic
• Specific Gravity : 1.010
• Albumin: ++
• Sugar: ++++
• Bile Salta and Pigments: Nil
• Pus cells: 3-6 /HPF
• Epithelial cells: 2-4 / HPF
• Red blood cell: NIL
• Casts: NIL

7. URINE FOR KETONE BODIES - 

On 9/06/2022

Positive 

On 11/06/2022

Negative 

 8. HEMOGRAM 

• Hemoglobin: 11.3mg/dl
• Total leucocyte count: 8900cell/cumm
• Neutrophils: 80%
• Lymphocytes:13%
• Eosinophils:02%
• Monocytes:05%
• PCV: 33.7 Volume%
• MCV: 75.4fl
• MCH: 25.3pg
• MCHC: 33.5%
• Platelet Count: 2.67 lakhs/cumm
• RBC Count: 4.47million/cumm
• PBS- Normocytic Normochromic

9. 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   

10. ABG Analysis

• pH     : 7.44
• pCO2 : 30.6mmHg
• pO2.  :71.4mmHg
• HCO3:22.6mmol/L
• BEB: -2.0mmol/L
• BEecf: -2.8mmol/L
• TCO2: 40.5VOL
• O2 Count: 18.0vol%
• O2sat:93.8%

   11. Seronegative for HIV, HEPATITIS B and C

12. USG- Mild hepatomegaly

   13. ECG:

14. X-RAY:

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