1601006100-short case

29YEAR OLD FEMALE WITH SOB, EDEMA,FACIAL PUFFINESS.

PATIENT CAME TO CASUALITY WITH cheif complaints of -

B/L PEDAL DEMA - 20 DAYS

FACIAL PUFFINESS - 20 DAYS

BREATHLESSNESS - 1 DAY 

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 YEARS BACK THEN WAS DIAGNOSED WITH DM-1 AND IS ON INSULIN MITARD (20U-X-16U).                 -SHE HAD 2 EPISODES OF WEAKNESS, UNCONTROLLED SUGARS FOR WHICH SHE WAS ADMITTED FOR A DAY &DISCHARGED ( 1ST EPISODE 5YEARS BACK AND 2ND EPISODE 3 YEARS BACK RESPECTIVELY).                                     -.ON NOV

2022 PATIENT WAS TAKEN TO GOVT HOSPITAL I/v/O SOB AND WAS DIAGNOSED WITH DENOVO HYPERTENSION, UNCONTROLLED SUGARS ( STARTED ON ? HTN MEDICATION).                            -.ON 2ND JAN 2023, SHE HAD EPISODES OF VOMITINGS, LOOSE STOOLS AND WAS ADMITTED IN AIIMS & WAS DIAGNOSED WITH   DIABETIC NEPHROPATHY, HTN ,VIT D DEFICIENCY .     

Hyperpigmented lesion on right foot.                                                                      -6 DAYS BACK SHE DEVELOPED PEDAL EDEMA AND SOB WHICH WAS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE (GRADE 2 TO 4) ASSOCIATED WITH ORTHOPNOEA AND WAS BROUGHT TO OUR HOSPITAL AS HER SYMPTOMS DIDN'T SUBSIDE.

PAST HISTORY:

K/C/O DM TYPE 1 SINCE 10 YEARS AND IS ON INSULIN

K/C/O HTN FROM 2 MONTHS AND ON T TELMA+CLINIDIPINE AND T METXL

H/O OF RIGHT EYE CATARACT SURGERY: 8 YEARS BACK

PERSONAL HISTORY:

APPETITE - NORMAL

DIET - MIXED

BOWEL AND BLADDER - REGULAR

SLEEP - ADEQUATE

GENERAL EXAMINATION:

PT IS concious , coherent, cooperative.

PALLOR: PRESENT

PEDAL EDEMA - PRESENT,PITTING TYPE, TILL KNEE NO ICTERUS,CYANOSIS,CLUBBING,

LYMPHADENOPATHY 

VITALS ON ADMISSION:

PR-113 BPM

BP- 220/120MM HG

RR- 26 CPM

SPO2- 72% AT RA

GRBS - HIGH

SYSTEMIC EXAMINATION:

1) PER ABDOMEN:

INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.

PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.

ASCULTATION: BOWEL SOUNDS - HEARD

2)RESPIRATORY SYSTEM:

INSPECTION: SHAPE OF THE CHEST IS ELLIPTICAL. B/L SYMMETRICAL.                            BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL VOCAL FREMITUS IS NORMAL

PERCUSSION: RESONANT BIL

ASCULTATION: BAE + , NVBS HEARD

3) CVS:

INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS,PULSATIONS.

PALPATION: APEX BEAT FELT IN LEFT 5TH ICS. NO THRILLS AND PARASTERNAL HEAVES.

ASCULTATION: S1S2 +,NO MURMURS

Diagnosis:

TYPE 1 DM WITH UNCONTROLLED SUGARS (RESOLVING)

WITH HYPERTENSIVE EMERGENCY (RESOLVED)

AND NECESSARY INVESTIGATIONS WERE DONE, HER SUGARS WERE FOUND TO BE HIGH AND BP BEING -220/110MMHG ON PRESENTATION AND WAS TREATED SYMPTOMATICALLY. REFRRALS WERE TAKEN FROM ENDOCRINOLOGIST I//O HIGH SUGARS.

  -INITIALLY FOR HYPERTENSION,SHE WAS TREATED WITH T. TELMA 40MG + CLORTHALIDONE 12.5MG AND T.METXL 25MG AND LATER ON WAS FIXED ON T.NICARDIA 20MG PO/BD(8AM-X-8PM) .

Follow up after starting treatment;

Bp timeline:

12pm-200/100

3pm-180/90

8pm-160/80

9pm-150/90

GRBs timeline:

6am-494

7am-499

2pm-456

7pm-254

Most recent follow up -                                            Bp time line 

1pm-126/73

3pm-124/76

10pm-108/62

Grbs:

1pm-222

8pm-98