Final practical exam- long case

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Date of admission: 3-02-2022

A 43 yr old female patient came to the casualty with a chief complaint of  lower backache since 2 days , pain abdomen and vomiting since 1 day 

HISTORY OF PRESENT ILLNESS:

Patient was apparantly asymptomatic 6 yrs back , then had anasarca went to the local hospital in Hyderabad and diagnosed to have hypothyroidism (started on tab.Thyronorm 50 microgram) & also got diagnosed for renal failure & was on tab.Torsemide 20 mg+ spironolactone 50mg and also DM ( started on inj.MIXTARD )

Currently patient complaints of pain abdomen which is diffuse , intermittent, dull aching pain associated with vomitings (2 episodes) , non bilious, non projectile, food as content

No history of fever, cold, cough, loose stools, constipation, Malena, haematuria.

No history of pedal edema, decreased urine output, facial puffiness.

PAST HISTORY:

patient is known case of DM since 6 yrs ( inj. MIXTARD 20U.....X...25U)

Hypothyroidism since 6 yrs ( tab thyronorm 25 micrograms)

Patient is not a known case of hypertension, bronchial asthma, epilepsy, tuberculosis

TREATMENT HISTORY:

- DM since 6 yrs ( using inj.MIXTARD 20U...X....25U)

- Hypothyroidism since 6 yrs ( tab. Thyronorm 25 micrograms)

PERSONAL HISTORY:

Diet : mixed

Appetite : decreased 

Sleep : adequate

Bowel& bladder : regular

No known addictions 

MENSTRUAL HISTORY:

Post menopausal since 2 yrs

FAMILY HISTORY:

History of similar complaints in family

GENERAL EXAMINATION: 

Patient is conscious, coherent, co- operative

PHYSICAL EXAMINATION:

 No pallor

No Icterus

 No clubbing 

No cyanosis

 No koilonychia

 No edema 

No Lymphadenopathy

Moderate dehydration present

VITALS: 

Temp- Afebrile

Bp-150/80 mmHg

Pr-88bpm

 Rr- 21cpm

Spo2-99% on RA

 GRBS: high

SYSTEMIC EXAMINATION : 

RS-  decreased breath sounds on B/L IAA & ISA 

Cvs-S1 S2 +

P/A - soft,  diffuse tenderness + 

Cns-   NAD 

GCS - 15/15

INVESTIGATIONS : (3/2/22)

ABG : 

PH - 7.21

PCO2- 25.8

PO2- 89.2

HCO3- 12

RBS : 560MG/DL

HBA1C : 8.1

HEMOGRAM : 

HB: 9.4

TLC : 13,200

RBC : 3.47million/cu3

Urine for ketone bodies : negative 

RFT :

sr cr : 4.6

Urea : 4.6

Na+ : 131

K+: 4.6

LFT : 

SGPT : 125

SGOT : 137

ALP : 372

TP: 5.5

ALB : 2.7

Sr. Amylase : 237

Sr. Lipase : 92

USG ABDOMEN : 

1.GB wall edema

2.Right mild pleural effusion 

3.No ascitis

Xray erect abdomen 

chest x- ray on 5/2/22

INVESTIGATIONS:

ECG:

TPR:

PROVISIONAL DIAGNOSIS :  

  pain abdomen secondary to uncontrolled sugars with DKA with ? (CKD secondary to metabolic acidosis ) with metabolic acidosis secondary to DKA & CKD with H/o DM, hypothyroidism  , CKD

TREATMENT PLAN: 

ON 3/2/22

1)IVF –  0.9%NS 1L FOR 1ST hour 

                              1L FOR 2ND hour 

                              1L FOR 3rd hour   

2) IVF – 0.9% NS @ 250ml/hr for next 6 hours 

3)INJ. HAI – 0.1IU /KG /B.wt  IV /STAT 

 4)INJ.HAI – 1ml in 39ml NS @ 6ml/hr infusion (according to ALGO 1  )

5 INJ. PANTOP 40mg IV/OD

6)INJ.ZOFER 4mg IV/SOS

TREATMENT ON 

4/2/22 & 5/2/22

1)  IVF – 0.9% NS @ 150ml/hr

2) INJ. PANTOP 40mg IV/OD

3)INJ.ZOFER 4mg IV/TID 

4) INJ. METROGYL 500MG /IV / TID

5) INJ. TRAMADOL 1AMP IN 100 ML NS /IV/TID 

6)INJ. INSULIN INFUSION WITH 2ML/HR 

7)INJ.BUSCOPAN 2CC IV/SOS

8)INJ.LASIX 40MG IV/BD

9) TAB.THYRONORM 50microgram PO/OD