GM Long Case

  Final Exam Practical Long Case

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Date of admission:- 3rd February 2022

A 43 year old female patient came to the opd with chief complaints of low backache since 2 days, vomitings and pain in the abdomen since 1 day. 

History of Present illness:-

Patient was apparently asymptomatic since 6 years ago.Then she had anasarca for which she was admitted in hyderabad. There she was diagnosed with hypothyroidism ,renal failure  and diabetes mellitus .

Now she came to opd with pain in the abdomen which is of diffuse ,intermittent ,dull aching pain associated with vomitings 2 episodes a day which is of non billious, non projectile and contains food particles. 

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

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

Past History:-

Patient has Hypothyroid since 6 years.

Patient also have Diabetes mellitus since 6 years. And also renal failure.

No history of Hypertension , asthma , tuberculosis, epilepsy.

Personal History :-

Patient has mixed diet.

Appetite is decreased.

Sleep is adequate.

Bowel and bladder movements are regular.

No addictions.

Menopause since 2 years.

Family history:- 

Her mother is a known case of diabetes mellitus. 

No other members in family has similar complaints.

Drug History:-

Patient is Diabetic so is on INJ. MIXTARD 20 units initially and increased to 25 units one and half year ago.

Patient has Hypothyroid so is  on Tab.THYRONORM 25 mg.

Patient has renal failure so is on Tab.Torsemide 20 mg+Spironolactone 50 mg.

General examination:-

Patient is conscious, coherent and cooperative well oriented to time, person and place. 

No anemia, no pallor, no icterus, no cyanosis, no clubbing of fingers, no generalised lymphadenopathy.

Vitals:-

Temperature-- afebrile

Respiratory rate-- 21 cycles per min.

Pulse rate-- 88 bpm

Blood pressure-- 150/80 mm Hg

Spo2-- 99% on RA 

GRBS -- High

Systemic Examination :-

CVS ---S1 S2 + , No murmurs.

Respiratory System--- decreased breath sounds

Per Abdomen - soft, diffuse tenderness +

 CNS -- no abnormalities detected.

GCS -- 15/15

Investigations:- on 3/3/22 

Hemogram: 

HB: 9.4

TLC : 13,200

RBC: 3.47million/cu3

RBS : 560MG/DL

HBA1C : 8.1

ABG :-

PH - 7.21

PCO2- 25.8

PO2- 89.2

HCO3- 12

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

TPR --

 

Complete urine examination--

 

Ultrasound

Color Doppler 2D echo--

ECG--

Bacterial culture and sensitivity report--

Chest X ray on 5/2/22

 

X ray of erect abdomen on 5/2/22

Provisional diagnosis:-

Pain abdomen secondary to uncontrolled sugars with DKA with ? pancreatitis with AKI on CKD. (CKD secondary to metabolic acidosis ) with HFPEF( EF- 58%) with metabolic acidosis secondary to DKA & CKD with H/o DM-2 , hypothyroidism , CKD

Treatment:-

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