Final Practical Exam Long Case

Long case

K.Shubankar

1701006169

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.

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever  

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 Presenting 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 diabetic mellitus and hypertension. She used medication for the same which was prescribed.

4 days back the patient stopped taking anti hypertensives and oral hypoglycemic agents 

Due to which she had 2-3 episodes of vomiting which was non bilious and non projectile and contained food particles, which was followed by giddiness.

Then she was taken to a local hospital, where she found her GRBS was 394 mg/dl and her urine sample was positive for KetoneBodies.

(Then she was referred to our Hospital).

No complaints of shortness of breath, chest pain, palpitations, syncopal attacks.

No complaints of burning micturition, loose stools, abdominal pain. 

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:

Diet: Consumes both Veg and Non-Vegetarian Foods.

Appetite:Normal

Sleep:Adequate 

Bowel and Bladder movements:Regular

Consumes Alcohol occasionally (90ml)

No history of any allergies. 

Family History:

Insignificant

Treatment History:

History of usage of oral hypoglycemic agents and anti hypertensive drugs

General Examination:

After taking informed consent patient was examined in a well lit room.

Patient was conscious coherent cooperative moderately built and nourished and well oriented to time place and person. 

Vitals: On 9th June 2022

Temperature: 99°F

Respiratory Rate:18cpm

Pulse Rate:96bpm

Blood pressure:230/100 mmhg

SpO2:97% on room air

GRBS:393mg/dl

No Signs of Pallor,Icterus,Cyanosis,Clubbing,Lymphadenopathy, Edema

Systemic Examination:

Respiratory system:Normal Vesicular Breath Sounds 

Bilateral Air Entry present

Cardiovascular system:S1 and S2 heard, No added murmurs

Central Nervous System: No focal Neural Deficit

PerAbdomen: Soft,Non Tender, No Abdominal Mass seen

Investigations:

Random blood sugar: 164mg/dl

Blood Urea: 26mg/fl

Serum Creatinine: 1.0 mg/dl

Electrolytes: 

Sodium - 139mEq/L  

Potassium- 3.3mEq/L.                                 

Chloride -98mEq/L

Complete urine examination:

Albumin: ++

Sugar: ++++

Pus cells: 3-6 /HPF

Epithelial cells: 2-4 / HPF

Red blood cell: NIL

Casts: NIL

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

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

Arterial blood gas:

pH: 7.44

pCO2: 30.6mmHg

pO2: 71.4mmHg

HCO3: 22.6mmol/L

O2sat:93.8%

Urine KETONE BODIES POSITIVE 

Glycated Hemoglobin: 6.5%

Seronegative for HIV, HEPATITIS B and C

ECG:

X-Ray: 

Provisional Diagnosis:

Diabetic ketosis with Hypertensive Urgency

Treatment:

Inj-Zofer (4mg I/V TID)

Inj-Pantop (40mg I/V OD)

Inj-Optinuron/NS (1 ampule/100ml I/V OD)

Tab-Nicardia (10mg PO)

Tab-Telma-Am (40/5 mg)

Inj-Human Actrapid Insulin (6 ml/hr I/V)