Final assessment-short case

February 08, 2022

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Date of admission - February 3

 43 year old female patient presented 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 back , then she had anasarca for which she was admitted in hyderabad. 

There she was diagnosed with hypothyroidism (tab. Thyronorm 50 micrograms ),renal failure (tab. Torsemide 20 mg+spironolactone50mg) and diabetes mellitus for which she was on injection Mixtard and increased in doses since 1 and half year. 

Now she presented to the 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 oedema, reduced urine output, facial puffiness. 

Past history-

Patient has diabetes mellitus since 6 yrs and on medication -injection  MIXTARD 20 units intially which is increased to 25 units one and half year back. 

Hypothyroidism since 6 yrs and on medication tab. Thyronorm 50 micrograms. 

Personal history : 

Diet - mixed 

Appetite - decreased

Sleep - adequate 

Bowel movements : regular .

Bladder movements : regular. 

No addictions. 

Family history:

Her mother is a known case of diabetes mellitus. 

Menstrual history:

Menopause since 2 yrs. 

General examination-

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

Physical examination:-

Pallor + 

No icterus

No cyanosis

No clubbing of fingers

No generalised lymphadenopathy

Moderate dehydration is present. 

Vitals-

Temp- Afebrile 

Bp-150/80 mm hg

Pr- 88bpm

Rr-21cpm

Spo2- 99% on RA

Grbs : High

SYSTEMIC EXAMINATION : 

RS- decreased breath sounds

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 : positive

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 ascites

Pallor + 

Complete urine examination

TPR:

Ultrasound of abdomen:

Hemogram:

ECG:

Chest x ray:

X ray of erect abdomen:

Review usg on 5/2/22

PROVISIONAL DIAGNOSIS : 

Pain abdomen secondary to uncontrolled sugars with DKA with pancreatitis with AKI on CKD .

Metabolic acidosis secondary to DKA

CKD with history of type 2DM with hypothyroidism

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