General medicine long case


Hall ticket number- 1601006169

“This is an online e-log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s informed consent.

Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

I have been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.


A 65 years old lady hailing from Miryalguda who is a farmer by occupation came on 23rd April, 2021 with the chief complaints of vomitings since 4 days.

History of present illness:-

She is a known case of Type-II Diabetes mellitus since 10 years and hypertension since 1 year and she is on medication for the both.

Then on 19th April, 2021 she developed vomitings which was- 

  • Sudden in onset.
  • 2 times per day.
  • Immediately after taking food
  • Non projectile, non bilious
  • Containing food particles
  • Yellowish in colour 
  • Non blood stained
  • Non foul smelling.
Then she developed constipation the next day.

On 20th April,2021 she went to Miryalguda owing to her complaints. After performing a couple of tests in Miryalguda, she was referred to KIMS, Narketpally in the view of elevated creatinine(6.5 mg/dl) and Blood Urea Nitrogen(171 mg/dl).

There is no history of fever.
No history of loose stools.
No history of Pain abdomen.
No history of Headache.
No history of syncope.
No history of dyspepsia, dysphagia.
No history of heartburn.
No history of abdominal distension.
No history of oliguria.
No history of hematuria.
No history of dysuria.
No history of Dyspnea.
No history of palpitations.
No history of chest pain.

Past medical history:-
  • No history of similar complaints in the past.
  • She has a history of Type- II Diabetes mellitus since the past 10 years.
  • She also has Hypertension since the last 1 year.
  • No history of Tuberculosis, Bronchial Asthma, Epilepsy, Thyroid problems.
Past surgical history: Underwent hysterectomy 20 years back.

Family history: 
  1. No similar complaints in the family.
  2. No history of Diabetes mellitus, Tuberculosis, Hypertension, Bronchial asthma, epilepsy in her family.
Personal history:
  • She has a mixed diet.
  • Her appetite is decreased.
  • Her sleep is adequate.
  • Bladder movements are normal but bowel movements are decreased.
  • She has No addictions.
Menstrual and Obstetric history: 
  • Attained menopause 20 years back.
  • Has 3 live children.
Drug history:
  • Insulin since 7 years.


  • Antihypertensives- Climidipine, Olmesartan Since 1 year
Treatment history: The treatment she has received so far:-
  1. I.V. Fluids- Normal Saline

2)Inj. Lasix (Loop diuretic) 


3)Tab. Cremaffin- laxative


4)I.V. Zofer- Antiemetic


5) Inj.Pantoprazole- Proton Pump Inhibitor

6) Inj. HAI

General Examination:
  1. She is conscious, coherent, cooperative, moderately built and moderately nourished, well oriented to day, time, place and person. 
  2. There is no pallor, icterus, cyanosis, clubbing, Lymphadenopathy.
  3. There is bilateral pitting oedema extending up to the ankles (Grade 1)




Vitals:
  1. She is afebrile.
  2. Pulse rate: 70 bpm, regular in rhythm, normal in volume and character, no radio-radial delay and no radio-femoral delay.
  3. Blood pressure: 160/80 mm Hg measured in right arm and in supine position.
  4. Respiratory Rate: 20 cpm 
  5. SpO2 at room air: 98%
Systemic Examination:

1) Gastrointestinal system:

   - Upper GIT: 
  • Lips - Normal
  • Teeth - Normal
  • Gums - Normal
  • Buccal mucosa -Normal
  • Tongue -Normal


  • Breath -Normal
   - Examination of abdomen:

        A) Inspection: 
  • Shape of abdomen - Normal
  • There is no fullness of flanks.
  • No venous prominence.
  • Umbilicus is central in position
  • Skin over abdomen- No scars, sinuses, ulcers, pigmentation and striae.
  • There is no localised swelling 
  • Movement of abdomen: 
               - All quadrants of the abdomen moving with respiration.
               - No visible pulsations.
               - No visible peristalsis.
  • Hernial orrifices are free.



         B) Palpation:

         - Superficial:-
  • No local rise of temperature.
  • No tenderness.
  • No guarding.
  • No rigidity.
         - Deep:
  • Liver: No tenderness
  • Spleen: Not palpable
Palpation of spleen-



  • There is no rebound renderness.
        C) Percussion: Tympanic note heard; Dull note heard over the upper border of liver and spleen.
                                  Liver span is normal
     

        D) Auscultation: Bowel sounds heard.

2) Cardiovascular system: 
  • JVP is normal.
  • S1, S2 sounds heard.
3) Respiratory system: Normal Vesicular Breath Sounds heard.

4) Central Nervous System: 
  • Higher mental functions- Intact
  • Motor system- normal
  • Sensory system- normal
  • Cerebellar system- Normal
From the history and examination, my provisional diagnosis is Diabetic Ketoacidosis with pedal oedema secondary to hypoalbuminemia caused by diabetic nephropathy.

Investigations:-

1) Complete Urine Examination:
  • Pus cells: 3-4
  • Epithelial cells: 2-4
  • RBCs: nil
  • Sugars: nil
  • Bile salts and bile pigments: nil 
  • Albumin: 2+
  • Spot urine Sodium: 153 mEq/L
2) Renal Function Test:
  • Serum urea: 199 mg/dl
  • Serum creatinine: 8.5 mg/dl
  • Serum uric acid: 7.8 mg/dl
  • Calcium: 10 mg/dl
  • Phosphorus: 4.7 mg/dl
  • Sodium: 135 mEq/L
  • Potassium: 4.2 mEq/L
  • Chloride: 106 mEq/L
3) ECG-



4) Chest X Ray: In AP view


From the investigations, I am of the opinion that it could be Acute Kidney Injury. The cause of her AKI could be-

• Pre renal: Volume depletion from excessive vomitings 



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