55year old lady with C/o chest pain,SOB since 3days

 02/03/2023

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Name: K. Thanmai(intern)

Roll no: 76

A 55year old lady came to casuality in wheelchair with complaints of

Chest pain since 3days

Shortness of breath since 3days

HOPI:

Patient was apparently asymptomatic 15years back,later she noticed a swelling in right foot and consulted doctor and there she was diagnosed as Diabetes Mellitus type 2 and was started on oral hypoglycemic agents(not documented)

Later she was fine with her regular works until 1month back

1month back she stopped taking OHA and took other tablets(?multivitamin ) which she considered as OHA.

Then since 10days she started having pain in the  left loin which was aggravated and radiating to chest since 3days.

C/o SOB since 3days along with the chest pain 

Not associated with cough,sputum

PAST HISTORY:

K/C/O DM2 since 15years and was on regular medication i.e OHA which was not documented and missed taking tablets 1month back

N/K/C/O HTN,ASTHMA, EPILEPSY,TB,CVA

PERSONAL HISTORY :

Occupation :Farmer

Appetite normal 

diet non veg 

bowel and bladder movements normal

Addictions : Toddy drinker from 20years of age and stopped 5years back

FAMILY HISTORY:

 Insignificant

MENSTURAL HISTORY

Attained menopause at 45years

GENERAL EXAMINATION :

patient is conscious cooperative coherent well oriented to time place person 

Pallor present 

No icterus, cyanosis, clubbing , lymphadenopathy, edema 

Vitals 

Temperature : 98.8°F

PR: 101bpm

RR:16cpm 

BP 120/60mmhg 

spo2: 96% at room air 

GRBS : High (at time of admission)

At 7pm 245gm%

Systemic examination :

CVS: S1S2 heard, no cardiac murmurs heard 

RS: NVBS heard, Dyspnoea present 

P/A: Soft,Tenderness at left loin and lumbar region

CNS : 

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- Both upper and lower limbs normal

                           Rt        Lt

Power-  UL:     4/5        4/5

                LL.     4/5       4/5

Reflexes          Right      Left

Biceps                 ++        ++

Triceps.              ++.        ++

Supinator           ++       ++

Knee.                   ++.      ++

Ankle                  ++.       ++

INVESTIGATIONS:

Hb:10.5g%

TLC:13,300cells/cumm

PLATELET COUNT:2.8 laks/cumm

PCV:33.1

CUE:

SUGARS:++++

ALBUMIN: +

SE.UREA:51

SE.CRETAININE:1.5

URINE FOR KETONE BODIES: NEGATIVE 

SODIUM:134

CHLORIDE:97

POTASSIUM:3.9

IONISED CALCIUM:1.02

LFT:

TB:0.80mg/dl

DB:0.19mg/dl

AKP:236IU/L

TP:5.1gm/dl

ALBUMIN:2.3gm/dl

A/G RATIO:0.87

ECG:

2D ECHO:

EF:63%

TRIVIAL no AR,TR,MR,

No RWMA, NOMS/AS,SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION,NO PAH/PE

CHEST X-RAY (PA VIEW)

USG ABDOMEN AND PELVIS:

B/L raised echogenicity of kidneys

PROVISIONAL DIAGNOSIS :

Uncontrolled sugars

TREATMENT GIVEN:

ON DOA:(02/03/2023)

1)IV.FLUIDS 1UNIT NS AND 1UNIT RL @75ml/hr

2)Inj. HUMAN ACTRAPID INSULIN SC/TID

3)INJ.PAN 40MG IV/OD

4)INJ.ZOFER 4MG IV/OD

5)TAB.PCM 650MG PO/TID

6)INJ.NEOMOL 1GM IV/SOS(IF TEMP >101°F)

7)GRBS 2ND HRLY MONITORING