Case 49 39 male with giddiness

Doa 7/12/23

Diagnosis

HYPERTENSION EMERGENCY[RESOLVED]

DIABETIS MELLITUS II

OLD CVA [RIGHT MCA INFARCT]

DIABETIC NEPHROPATHY

Case History and Clinical Findings

PATIENT WAS BROUGHT TO CASUALITY WITH C/O GIDDINESS SINCE MORNING

C/O SLURRING OF SPEECH SINCE MORNING

PATEINT WAS APPARENTLY ASYMPTOMATIC TILL MORNING THEN HE HAD GIDDINESS

WHICH WAS SUDDEN IN ONSET WHILE TRAVELLING ON BIKE PATIENT HAD WEAKNESS OF

LEFT UPPER LIMB AND THEN HAD GIDDINESS SUDDEN IN ONSET

NO INVOLUNTARY MOVEMENTS ,NO LOSS OF CONCIOUSNESS ,NO ALTERED SENSORIUM

NO RESTRICTION OF MOVEMENTS OF EYEBALLS

SLURRING OF SPEECH SINCE MORNING WITH DEVIATION OF MOUTH TOWARDS RIGHT

SYMPTOMATIC TREATMENT WAS GIVEN FOR ABOVE MENTIONED COMPLAINTS

IV FLUIDS -NS@20ML/HR

INJ.LEVIPIL 500MG 12 HRLY

INJ.PIPTAZ 2.25GM 8TH HRLY FOR 5 DAYS

INJ.LASIX 20MG IV/BD

INJ.CALCIUM GLUCONATE 1000MG IN 100 ML NS OVER 1 HOUR

INJ.25D WITH 10U HAI IV/STAT OVER 1 HOUR

INJ.HAI S/C TID 6 U-6U-6U

TAB.ECOSPIRIN 150MG OD

TAB.CLOPIDOGREL 75 MG OD

TAB.ATORVAS 40 MG OD

TAB.MINIPRESS -XL 2.5MG OD

TAB.CILINIDIPINE 10 MG BD

TAB.NODOSIS 500MG BD

TAB.SHELCAL OD

POTASSIUM BINDING SACHETS 1 IN 1 GLASS OF WATER OD

OPHTHALMOLOGY REFERRAL WAS DONE ON 9/12/23 I/V/O DIABETIC AND HYPERTENSIVE

RETINOPATHY CHANGES

IMPRESSION:

1.RETINOPATHY CHANGES NOTED-

RIGHT EYE- MODERATE NON PROLIFEARTIVE DIABETIC RETINOPATHY WITH

HYPERTENSIVE CHANGES GRADE I

LEFT EYE-MILD NON PROLIFEARTIVE DIABETIC RETINOPATHY WITH HYPERTENSIVE

CHANGES GRADE I

2.USE OF SPECTACLES FOR REFRACTIVE ERROR

NEPHROLOGY REFERRAL WAS DONE ON 11/12/23 I/V/O RAISED CREATININE AND UREA

-ADVICED HEMODIALYSIS BUT PATIENT REFUSED .

TREATMENT:

INJ.ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE

INJ.IRON SUCROSE 100MG WEEKLY ONCE

TAB.LASIX 40 MG BD

UROLOGY REFERRAL WAS DONE I/V/O TRAUMATIC RUPTURE OF URETHRA

TREATMENT:

INJ.TRANEXA 500MG IV/BD FOLLOWED BY TAB.TRANEXA 500MG PO/BD TILL HEMATURIA

SUBSIDES.

PAST HISTORY:

K/C/O HTN SINCE 3 YEARS

AS TAB TELMA 40MG OD

K/C/O DM II SINCE 4 YEARS ON TAB GLIMI M1 OD

K/C/O CVA RT MCA INFARCT 3 YEARS AGO

PERSONAL HISTORY

MIXED DIET

APPETITE -NORMAL

BOWEL -REGULAR

MICTURITION -NORMAL

NO KNOWN ALLERGIES

FAMILY HISTORY - NOT SIGNIFICANT

GENERAL PHYSICAL EXAMINATION

PT IS CONSCIUOUS, COHERENT, COOPERATIVE WELL ORIENTD TO TIME, PLACE, PERSON

MODERATELY BUILT AND NOURISHED

VITALS

BP : 170/100MM HG

PR 105 BPM

SPO2 98 % AT RA

TEMP 98.3 F

GRBS-196 MG/DL

NO PALLOR , CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA

ICTERUS PRESENT

SYSTEMIC EXAMINATION

CVS S1 AND S2 +

RS NVBS HEARD, BAE +

CNS - RT LT

TONE UL N N

LL N N

POWER UL 5/5 5/5

LL 5/5 5/5

REFLEXES

B +2 +2

T +2 +2

S `1 + +1

K +2 +2

A 1+ +1

P F F

P/A - SOFT,NON TENDER

Investigation

HEMOGRAM:-

HB- 14.2 GM/DL

TLC- 14700 CELL CUMM

PLATELETS- 3.33 L CUMM

FBS 124 MG/DL

RFT

UR: 97MG/DL

CR: 1.5 MG/DL

URIC ACID: 9.8 MG/DL

CA+2: 9.7MMOL/L

NA+:136 MEQL

K+: 3.5MEQL

CL-: 98 MEQL

ECG NORMAL SINUS RHYTHM

SEROLOGY: NEGATIVE

CUE: PALE YELLOW COLOUR , ACIDIC IN REACTION

PUS CELLS: 2-3

EPITHELIAL CELLS: 2-3

LFT :

TB - 0.80

DB- 0.19

AST- 20

ALT- 19

ALKALINE PHOSPHATE -156

TP: 7.1

ALBUMIN- 3.O

A/G- 0.75

FBS -205

PlBS - 186

GLY HB- 7

2D ECHO: MILD AR REIVIAL MR/ TR

NO RWMA, NO AS/MS, SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION (+), NO PAH.

USG ABDOMEN DONE ON 8/12/23

IMPRESSION

RAISED ECHOGENICITY OF BILATERAL KIDNEYS

MDCT WAS DONE ON 7/12/23

IMPRESSION:

1.OLD INFARCT WITH ENCEPHALOMELACIC CHANGES IN RIGHT TEMPORAL AND OCCIPITAL

LOBES EXTENDING INTO RIGHT PARIETAL LOBE

2.FEW HYPODENSE AREAS IN BRAINSTEM -?ARTEFACT ,?INFARCT

3.SUGGEST MRI WHEN THE PATIENT IS STABLE

2D ECHO WAS DONE ON 8/12/23

-NO RWMA

-CONCENTRIC LVH + 1.3CMS

-NO MR/AR;TRIVIAL TR +

-NO AS/MS

-EF=58,RVSP-35MMHG

-GOOD LV SYSTOLIC FUNCTION

-NO DIASTOLIC DYSFUNCTION

-IVC SIZE (1.12CMS) COLLAPSING

-MILD DIALTED LV

USG ABDOMEN:

RAISED ECHOGENICITY OF BILATERAL KIDNEYS

Treatment Given(Enter only Generic Name)

INJ LEVIPIL 1G IV STAT

TAB ECOSPRINE 300MG PO/STAT

TAB CLOPIDOGREL 150MG PO/STAT

TAB ATORVAS 80 MG PO/STAT

TAB NICARDIA 10MG PO/STAT

INJ LASIX 200MG IV STAT

INJ CALCIUM GLUCONATE 1000MG IN 100ML NS OVER 1 HOUR

TAB CINOD 10MG BD

INJ 25 D WITH10 UNITS HAI IV STAT OVER 1 HR

INJ PIPTAZ 225 GM IV /TID 8TH HOULY

INJ H ACTRAPID S/C TID 6U-6U-6U

GRBS 7. PROFILE

BP PR HOULY MONITORING

Advice at Discharge

FLUID RESTRICTION <1.5 LITRES /DAY

SALT RESTRICTION <2G/DAY

INJ H ACTRAPID S/C TID 6U-6U-6U X 1 MONTH

TAB. LEVIPIL 500MG BD X 1 MONTH

TAB ECOSPRINE 300MG POX 1 MONTH

TAB CLOPIDOGREL 75MG POX 1 MONTH

TAB ATORVAS 40MG PO X 1 MONTH

TAB.MINIPRESS XL 2.5 MG ODX 1 MONTH

TAB CILINIDIPINE 10MG PO/BD X 1 MONTH

TAB.SHELCAL CT PO/OD X15 DAYS

Follow up in june 2024

Ckd conservatively managed

Fbs 134 mg/dl plbs 167 mg/dl hba1c 6.7 mg/dl

Follow up in february

Dialysis dependant

Fbs 108mg/dl

Plbs 147 mg/dl

Hba1c 6.5 %