1801006155 - SHORT CASE

A 29 Y/O FEMALE WITH SOB, EDEMA AND FACIAL PUFFINESS.

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CHIEF COMPLAINTS - 

Patient came to casuality with chief complaints of
- Bilateral pedal edema - 20 days
- Facial puffiness - 20 days
- Breathlessness - 1 day 

HISTORY OF PRESENT ILLNESS - 

Patient was apparently asymptomatic 10 years back,  then was diagnosed with Diabetes mellitus type 1 and is on insulin mixtard (20u-x-16u). She had 2 episodes of weakness, uncontrolled sugars for which she was admitted for a day and discharged ( 1st episode 5 years back and 2nd episode 3 years back respectively). 

Three months ago patient was taken to govt hospital i/v/o sob and was diagnosed with denovo hypertension, uncontrolled sugars and started on medication .

1 month ago she had episodes of vomitings, loose stools and was admitted in aiims & was diagnosed with pancytopenia, diabetic nephropathy, dilated cardiomyopathy, vit d deficiency. 

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  tab.telma+clinidipine and tab.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:

GENERAL EXAMINATION - 

Patient is conscious coherent and cooperative, well oriented to time place and person

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.
Auscultation: 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 and vocal fremitus is normal
Percussion: resonant bilaterally 
Auscultation: 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


4) CNS:
Patient was c/c/c.
Higher mental functions- intact
Gcs - e4v5m6
B/l pupils - normal size and reactive to light
No signs of meningeal irritation,cranial nerves- intact, sensory system-normal,
Motor system: tone- normal, power- 5/5 in all limbs reflexes: biceps - 2+, triceps-2+, supinator + , knee - 2+, ankle - 2+


Diagnosis:

Type 1 dm with uncontrolled sugars (resolving)
With hypertensive emergency (resolved)

? Nephrotic syndrome

? Heart failure 

HTN SINCE 2 MONTHS & DM SINCE 20 YEARS 

Lab Investigations - 

1) Hemogram - 

    Haemoglobin: 8.1 gm/dl

    Total count: 5,600 cells/cumm

    Neutrophils: 89 %

    Lymphocytes: 07 %

    Eosinophils: 00 %

    Monocytes 04 %

    Basophils: 00 %

    PCV: 24.7 vol %

    MCV: 97.6 fl

    MCH: 32.0 pg

    MCHC: 32.8 %

    RDW-CV: 15.0 %

    RDW-SD: 53.1 fl

    RBC count: 2.53 millions/cumm

    Platelet count: 80.000 lakhs/cu.mm

 

2) Serum electrolytes and serum ionized calcium-

     

     Sodium - 139  mEq/L

     Potassium - 4.7 mEq/L

     Chloride - 103 mEq/L

     Calcium ionized - 1.15 mmol/L

3) Liver function tests - 

     Total bilurubin - 1.47 mg/dl

     Direct bilurubin - 0.44 mg/dl

     SGOT (AST) - 39 IU/L

     SGPT (ALT) - 18 IU/L

     Alkaline phosphate - 103 IU/L

     Total proteins - 5.6gm/dl

     Albumin - 3.0 gm/dl

     A/G ratio - 1.23

4)  RBS 409 mg/dl

5)  Serum creatinine - 1.0mg/dl

     Blood urea - 83 mg/dl

TREATMENT:

1.IVF NS @ 30 ml/ hr

2.Strict diabetic diet

3.inj lasix 40 mg iv bd

4.T.telma 40 mg po bd

5.t metxl 25mg po od 

6. T. Clinidipine 10 mg po bd

7.T.Nicardia 20 mg po bd

8. inj h.actrapid insulin according to grbs

9. Inj. glargine 10 u @ 10pm

10. T.Thyronorm 25mcg po od