Final practicalexam medicine short case

 

 1701006082;( short case)

I’ve 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

K.shirisha

Hall ticket number; 1701006082

9th semester.  

Short case discussion;

75 year old male farmer by occupation resident of aregudem brought to the casualty on 7/6/22 

Chief complaints;

Decreased responsiveness since 5 am on 7/6/22 and not able to speak

He was presented to casuality at at 10;35 am at that time his grbs was43mg/dl

History of present illness;

The patient was apparently asymptomatic 15 years back then he had fever,weakness and increased urine output then he visited local hospital and sugar test was done and diagnosed as Type 2 diabetes mellitus.and prescribed a medicine( metformin500mg+glimeperide2mg+voglibose0.2 mg).

On 7/6/22;

He was unconscious,and not able to speak since 5 am and he was presented to our hospital at 10;35 am at that time his GRBS was 43 mg/ dl.

Since last 2 days he had not taken meals and consumed alcohol

C/O excessive sweating, tremors , generalized weakness, fatigue,lethargy

C/ o decreased urine output since 2 days

C/o polyuria,polydipsia,polyphagia

No c/o blurring of vision, headache,nausea,abdominal pain, 

Past history:

He had similar complaints in the past 6 years ago of decreased responsiveness due to low grbs and was treated in a local hospital with IV fluids

Not a k/c/o hypertension, coronary artery disesase,asthma, epilepsy,

Treatment history:he was on 

metformin500mg+glimeperide2mg+voglibose0.2 mg). Since 15 years

Surgery : he underwent for cataract surgery for left eye 2 years ago

Family history : insignificant

Personal history;

Diet ; mixed

Appetite : normal

Bowel ; regular

Bladder: increased urine output

Sleep; adequate

Addictions: chronic alcoholic since 45 years

General examination; 

Patient was unconscious at the time of presentation .

Now he was conscious, coherent, cooperative ,moderately built and nourished

Pallor : present( mild)

No icterus,cyanosis,clubbing lymphadenopathy,edema

Vitals;

Temperature: afebrile(98.6° f)

Pulse; 52bpm, regular,normal volume

Blood pressure120/80mmhg

Respiratory rate: 18cpm

Spo2 ;97% @RA

Systemic examination;

Respiratory system;

Inspection of upper respiratory tract

Oral cavity ; normal

Nose; no DNS,polyp

Pharynx ; normal

Lower respiratory tract

Position of trachea; midline

Position of Apex beat; left5ics 1cm medial to mid clavicular line

Symmetry of chest : symmetrical and elliptical

Movement of chest ; normal

 

Palpation ;

Position of trachea,apical pulse is confirmed

No tenderness over chest wall,no crepitation s,no palpable added sounds,no palpable pleural rub

Percussion;

Resonant note heared,no obliteration on traubes space

Auscultation ; 

BAE-PRESENT

Normal vesicular breath sounds,no wheeze or no adventitious sounds

GIT;

Per abdomen;

Shape; scaphoid

Umbilicus; central

Movements ; normal

No visible pulsations or engorged veins,no visible peristalsis

Skin over abdomen ;normal

Palpation; hepatomegaly - no

* no tenderness,or local rise of temperature

Percussion ;

Liver; resonant note heared

No fluid thrills,shifting dullness

Auscultation;

Bowel sounds are heared

Cardiovascular system;

Inspection;

Position of trachea ;midline

No visible pulsations, raised jvp

Precordial bulge : absent

Shape of chest; bilaterally symmetrical

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

Palpation; no palpable thrills,parasternal heaves are palpable

Percussion ; 

Auscultation; S1,S2 heart sounds are heared , no added murmurs,

Central nervous system;

Higher mental functions : 

Level of consciousness: normal

Speech : normal

Mental state;

Memory;  normal,meningeal signs; negative

Cranial nerves;

1 ) olfactory nerve ; percieves smell

2) optic nerve :  

Visual acuity ; decreased in right eye

3) occlomotor nerve ; normal

4) trochlear nerve ;  normal

5) trigeminal nerve ; normal

6) abducens nerve ; normal

7) facial nerve; normal

8) vestibuli cochlear nerve; normal

9) glossopharyngeal nerve; normal

10)vagus

 nerve ; normal

11) spinal accessory nerve ; normal

12) hypoglossal nerve ; normal

Gait: normal

Motor system ;

Power  U/L         L/L

   Right   5/5        5/5

    Left      5/5        5/5

Tone        U/L                    L/L

Right       normal.        Normal

Left          Normal             Normal 

Reflexes   Biceps triceps supinator knee ankle 

Right             2+             2+            2+      2+.   2+

Left                  2+             2+.          2+.   2+.   2+

Plantar reflex: flexor

Sensory system : normal

Cerebral signs;

Finger nose in coordination; yes

Knee heel in coordination; yes

Investigations,;

Complete blood picture;

HB ; 10.9

Total leucocyte count;

7100

Neutrophils- 85

Lymphocytes- 10

Eosinophils-2

Monocytes- 3

Basophils-0

PCV-33.1

MCV- 81.9

MCH-27

MCHC-32.9

RDW-13.7

RBC-4.04

Platelet count- 3.82

Random blood sugar-114

Renal function tests;

Blood urea,-55

Serum creatinine- 2.2

Serum sodium- 139

Serum potassium-3.4

Serum chloride- 98

Liver function tests:

Total bilirubin: 0.52

Direct bilirubin: 0.18

SGOT: 16

SGPT;13

Alkaline phosphatase; 98

Total protein: 5.8

Albumin; 3.6

A/G ; 1.65

Complete urine examination;

Color : pale yellow

Appearance: clear

Specific gravity: 1.010

Albumin: +

Sugar: nil

Bile salts; nil

Bile pigments: nil

Pus cells; 3-4

Epithelial cells: 2-3

RBC: nil

Crystals: nil

9/6/22

Fasting blood sugar; 70mg/dl

Ultrasound;

B/L Grade-2 renal parenchymal disease

Borederline prastatomegaly

ECG;

Interpretation; long PR interval,interventricular conduction defect.

Chest x ray

Provisional diagnosis; Altered sensorium ( improved) 2° to oral hypoglycemic agents induced hypoglycemia

Chronic kidney disease

( Diabetic nephropathy).

Treatment;

1)IV fluids DNS @ 50ml/ hour continuous infusion

2) inj optineuron 1 ampoule in 100ml NS/IV/ of

3) inj 25% dextrose IV /sos if grbs <70mg/dl

4) inj pantop 40 mg/po/ of

5) grbs monitering hrly

6) if grbs < 70 or > 250mg/dl start insulin