Case report of a patient with diabetic ketosis and hypertensive urgency
LONG CASE - FINAL MBBS PART 2 PRACTICAL EXAMINATION.
NAME : M.VARUN SAI
HALL TICKET : 1701006099.
ARTERIAL BLOOD GAS ANALYSIS ::
LIVER FUNCTION TEST ::
RENAL FUNCTION TEST & ELECTROLYTE LEVELS ::
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CONSENT AND DE-IDENTIFICATION :
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 whatsoever.
CASE REPORT ::
This is a case of a 75year old woman who is a housewife , resident of miryalaguda was brought to the casuality with
CHIEF COMPLIANTS ::
*Giddiness since 1day
* vomitings since 1day .
HISTORY OF PRESENT ILLNESS ::
Patient was apparently asymptomatic 6years back and was able to perform her regular activities without any difficulty then she experienced headache and generalised weakness for which she consulted a local medical practitioner and was diagnosed with TYPE 2 DIABETES MELLITUS and HYPERTENSION. She was prescribed with medicines ( oral hypoglycemic drugs and antihypertensive drugs) and was on regular medication.
4 days back she went to her relatives house and has a H/O no intake of antihypertensives and oral hypoglycemic drugs due to which she developed vomitings and giddiness.
VOMITINGS -
* Sudden onset
* Non bilious , non projectile , non foul smelling.
* Food particles as content .
* Not associated with fever , pain abdomen and loose stools.
She was taken to the local hospital and was found to have General random blood sugar ( GRBS) 394mg/dl.
And also urinary ketone bodies were positive .
No H/O chest pain , palpitations , syncopal attacks.
No H/O shortness of breath , burning micturition .
PAST HISTORY :
No similar compliants in the past.
Not a known case of tuberculosis , Coronary artery disease, epilepsy , asthma .
Surgical history : H/O cataract surgery 3 back in right eye and 2 yrs back in left eye .
PERSONAL HISTORY:
Mixed diet
Appetite normal
Sleep adequate
Bowel and bladder regular
Addictions : chutta smoking for 10years , 3 chutta per day and stopped 5 years back.
Intake of alcohol and toddy on social gatherings.
FAMILY HISTORY ::
Not significant.
No H/O Tuberculosis, epilepsy, asthma .
GENERAL EXAMINATION ::
Patient is conscious, coherent and cooperative ,
well oriented to time, place , person.
Moderately built and nourished.
Patient was examined in supine position in a well lighted room after taking consent.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Edema - absent
VITALS :
Temperature - afebrile
Pulse rate - 90beats per minute , regular volume and character , no radio radial and radiofemoral delay.
Respiratory rate - 20cycles per minute
Blood pressure - 230/110mmHg at the time of presentation.
On 10 /06/2022 - 150/100mmHg .
GRBS - 394mg/dl ( at presentation)
On 10/06/22 - 226mg/dl .
SYSTEMIC EXAMINATION ::
GIT
INSPECTION ::
Abdomen - distended
Umbilicus - transverse slit like
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
LIVER: no hepatomegly
SPLEEN- not enlarged
KIDNEYS - bimanual palpable kidneys
PERCUSSION ::
no shifting dullness
AUSCULTATION ::
Bowel sounds are heard and are normal
No bruit.
Other system examination ::
RESPIRATORY SYSTEM -
Bilateral air entry present ,
normal vesicular breath sounds heard , no adventitious sounds heard .
CVS- S1 , S2 heard , no thrills and murmurs heard .
CNS - no abnormality detected .
Higher mental functions
conscious
oriented to person and place ,time.
memory - able to recognize their family members
Speech - normal
Cranial nerve examination -
C. N. 1 - sense of smell present
C. N. 2- Direct and indirect light reflex present
C. N. 3,4,6 - no ptosis Or nystagmus C. N. 5- corneal reflex present on both sides
C. N. 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present.
C. N. 8- able to hear
C. N. 9,10- uvula not deviated
C. N.11- sternocleidomastoid contraction present
C. N. 12- no tongue deviation
Motor system
Tone -. Upper limbs Lower limbs
Inspection - Normal Normal
Palpation - Normal Normal
Muscle bulk - Normal in both upper and lower limbs.
Muscle power -
Right Left
Biceps- 5/5 5/5
Triceps-. 5/5 5/5
Brachioradialis-. 5/5 5/5
Tibialis posterior-. 5/5 5/5
Reflexes: Right Left
Biceps- + +
Triceps- + +
Supinator- + +
Knee- ++ ++
Ankle - + +
DIAGNOSIS :: ? HYPERGLYCEMIA AND HYPERTENSIVE URGENCY (2⁰ to non compliance to medication) .
INVESTIGATIONS ::
Urinary ketone bodies - positive .
COMPLETE BLOOD COUNTS :
ECG ::
2D ECHO :
PROVISIONAL DIAGNOSIS ::
DIABETIC KETOSIS WITH
HYPERTENSIVE URGENCY.
TREATMENT ::
1. I.v fluids (normal saline,ringer lactate) at 100ml/hr.
2. Inj. Human actrapid insulin i.v. infusion at 6ml/hr.
3. Inj.Zofer 4mg i.v. /TID
4. Optineuron 1 ampule in 1000ml NS i.v. OD
5. Nicardia 20mg PO stat.
6. Hourly GRBS , B.P. , vitals monitoring.
7 . Strict I/O charting.
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