202300982

 

 

 

Case History and Clinical Findings

Chief complaints : Difficulty in breathing since yesterday morning

Patient was apparently asymptomatic since 30 years. He then had burning sensation in feet and went to hospital. Necessary investigations were done and diagnosed with diabetes mellitus 2 and hypertension .with 150/100mmhg On metformin for 27 years , amlodipine 10mg

Burning sensation of feet and fatigue went to hospital at Nalgonda again three years ago . Was advised insulin. 30u morning and 15u night used for one year still uncontrolled diabetes so changed to mixtard 25u morning and 20u at night, later changed to 20u morning and 15u night since 2 years . Along with insulin also added gliclazide extended release tablets 60mg (recluse-XR 60) but defaulter.

Five years ago had UTI renal calculi post surgery was uneventful. Post surgery 8 months Investigations showed increase in creatine levels 1.6-2.0. Tab nodosis and uremax (sodium bicarbonate)500mg -2000mg per day on increased creatine levels >2.<2 1000mg

Three years ago left hand weakness mouth deviation slurred speech mri brain was done and medications were given

 

Attacks of giddiness , unstable gait, swaying gait and slurred speech came to kamineni neuro opd MRI brain was done in 2021. ?hemorrhagic clot and medicines were prescribed.

Two years ago had an episode of epilepsy due to ?hypoglycemic episode was advised Ecospirin 150/70mg H/S.

Bilateral pedal edema pitting type present, burning micturition, decreased urine output, SOB grade 4 spo2 75% at room air. Fever at night not associated with chills and rigor , relived after one hour on taking Dolo 650mg taken , after one hour again had episode of fever, relived after one hour of taking Dolo 650mg. Cough with expectoration present.

Left limited mobility and pain on shoulder movement. MEDICAL HISTORY:

* She is under medication ( MET XL - metoprolol and inj. Human mixtard , tab. Aspirin, tab. Clopitab

)Not a K/C/O asthma / Ischemic heart disease / epilepsy / TBFAMILY HISTORYNo significant family historyPERSONAL HISTORYOCCUPATION : House wifeDIET : MixedAPPETITE : NormalSLEEP : NormalBOWEL AND BLADDER HABITS : NormalADDICTIONS: NoGENERAL EXAMINATION*

Patient is concious coherent and coperative, well oriented to time palce and person* Built - moderately built , moderately nourishedVITALSBlood pressure: 130/60 mm hgPulse Rate: 95 bpmRR: 27 cpmTemperature: 99.5 degrees FSPO2: 91% under 8L of O2EDEMA OF FEET:PRESENT ; PITTING TYPE*NO PALLOR,ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHYSYSTEMIC EXAMINATION

RESPIRATORY SYSTEM :

Inspection : bilateral symmetrical chest

Palpation: trachea centrally placed, bilateral symmetrical chest movements Percussion: resonance

Auscultation: diffused wheezes and crepts in left and right sides of chest PER ABDOMEN :

Inspection: distended Palpation :soft non tender

Auscultation: bowel sounds heard Percussion: shifting dullness present CVS:

S1 S2 heard, JVP raised CNS:

no focal deficit

COURSE IN THE HOSPITAL :

 

62 year old male was bought to casualty with above mentioned complains. At the time of admission his vitals were bp : 160/90 mm hg, RR: 35 cpm on examination respiratory - diffused creptsCVS-s1s2 JVP raisedBilateral pitting pedal edema Managed with inj Lasix40mg and his abg showed dercresed po2 &pco2 ; diagnosed as type 1 respiratory failure and managed with cpap with community acquired pneumoniaSymptoms subsided.patient hemodynamically stable and planned for discharge

Rr trends :

on 6/1/23 - 35 cpm on 7/1/23 - 24 cpm on 8/1/23 - 16 cpm on 9/1/23 - 18 cpm on 10/1/23 - 20 cpm on 11/1/23 - 20 cpm grbs trends :

on 6/1/23

10 pm - 127 mg/dl 12 am - 130mg/dl 2 am - 127mg/dl

4 am - 190 mg/dl on 7/1/23

8 am - 183 mg/dl

4 pm - 289 mg/dl

8 pm - 258 mg/dl

10 pm -127 mg/dl

4 am - 97 mg/dl on 8/1/23

8 am - 125 mg/dl

10 am - 276 mg/dl

12 pm - 262 mg/dl

4 pm - 171 mg/dl

8 pm - 193 mg/dl

10 pm - 462 mg/dl

12 am - 353 mg/dl

2 am - 179 mg/dl on 9/1/23

 

8 am - 181 mg/dl 2pm - 495 mg/dl 4 pm -201 mg/dl

8 pm - 105 mg/dl on 10/1/23

8 am - 200 mg/dl on 11/1/23

8 am :152 mg/dl

Nephro opinion was taken and advice followed Pulmo opinion was taken and advice followed Optho opinionwas taken and advice followed Dac opinionwas taken and advice followed Investigation

2D ECHO -

EF : 58 %

RUSP : 30 MM HG CONCLUSION :

1)  MILD AR+, TRIVIAL TR+ | NO MR

2)  NO RWMA NO AS/MS, SCLEROTIC AV

3)  GOOD LV SYSTOLIC FUNCTION

4)  DIASTOLIC DYSFUNCTION. NO PAH/PE CBNAAT OF SPUTUM - NEGATIVE

RAT FOR COVID - NEGATIVE

C/S OF SPUTUM - ZN STAIN: NO ACID FAST BACILLI SEEN

GRAM STAIN: >30 EPITHELIAL CELLS/CPF, 2-3 PUS CELLS/CPF &GRAM POSITIVE COCCI IN SINGLES, PAIRS, CHAINS , FEW GRAM POSITIVE BACILLI AND FEW GRAM NEGATIVE BACILLI NORMAL OROPHARYNGEAL FLORA GROWN

Treatment Given(Enter only Generic Name)

Restriction of fluid <1.5 lts/ dayRestriction of salt <2 gm/dayInj.lasix 40 mg Iv/bdIntermittent CPAPSalbutamol nebulization 8th hrlyT.Nodosis 500 mg po/bdT.Shelcal 500 mg po/bdT.Carvedilol 3.125mg po/bdCap.Bio d3 po/OD weekly onceHAI acc to grbsInj.piptaz 225 mg IV/TIDSyrup Cremaffin 15ml po/TidT.Ultracet po /Qid

Advice at Discharge

 

T augmentin 650mg po/BD *5daysT nodosis 500mg po/BD *7 daysT shelcal po/OD at 2pm *7daysT mvt po/od *7daysCap Bio D3 po/ weekly onceSyrup ascoril ls 2tsp po Syrup cremaffin 15ml po/tid

*7daysInsulin HAI s/c8-8-6units before foodHome GRBS monitoring