1801006049 LONG CASE

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A 60 year old man resident of Sangaram, Nalgonda who was a farmer by occpation came with chief complaints of both lower limbs edema since 10days, upper limbs edema since 5days and vomitings, loose stools and decreased urine output 

History of presenting illness:

Patient was apparently asymptomatic 10days back then he developed bilateral pedal edema which was insidious in onset and gradually progressive 

He also developed upper limbs edema since 5days

H/o 6episodes of vomitings which are non bilious non projectile and food as content and 4episodes of loose watery stools 

Sequence of events:

18years ago patient’s sister’s death occurred which disturbed the patient emotionally and he did not have food for 2-3days.

At that time patient has involuntary passage of stool and was taken to a hospital and was diagnosed with diabetes mellitus and was on kept on OHA

8years ago he met with an accident and has injured his right shoulder for which he was given surgical treatment 

4years ago while he was cutting trees, a log has fell on his right lower limb and got his right knee and was treated with surgery 

2years ago he developed altered sensorium and had high sugars then he was diagnosed to have DKA and was treated accordingly 

4months back he complained of pedal edema and went to a hospital in Nalgonda and the edema got resolved in a week but then he developed vomitings for 3days which are non bilious and non projectile and then had altered sensorium and was brought to our hospital and was found out to be having hyponatremia and hypokalemia which were corrected with 3%NS and later with in 1-2 days patient became normal

10days ago patient developed pedal edema for which he went to a hospital in nalgonda again and was treated for 4days and on 10/3/23 he suddenly started having vomitings(6 episodes of vomitings in 2 days) and loose watery diarrhoea (4 episodes) later on his sensorium deteriorated and has decreased urine output and was brought to our hospital on sunday night(12/3/23).

Past history:

Patient is a known case of diabetis mellitus since 10years and is on Tab. Glimipride 1mg before breakfast and Tab. Metformin 500 mg after breakfast.

He is also a known case of hypertension since 4years and is on medication (Tab. Telma H(TELMISARTAN 40 mg+ hydrochlorthiazide 12.5mg) in morning and Tab. Cilacar 10mg at night)

He has no Tuberculosis, Asthma, Epilepsy, Coronary artery disease

Personal history: 

He takes mixed diet, has decreased appetite, sleep is adequate, bowel movements are regular.

Addictions: He was a chronic alcoholic and chronic smoker but stopped taking 20years ago

Daily routine:

He wakes up at 6 am in the morning and does his morning activities will have breakfast by 8 am and stays at home (he used to go to work in fields and sometimes cutting trees) and will have his lunch by 1 pm which consists of rice and curry and comes to the home by 5 or 6 pm when he used to work and will have dinner by 8pm and goes to bed by 10pm.

Family history 

No member of the family has similar complaints 

General examination:

Patient is conscious, coherant, cooperative. He is moderately built and moderatly nourished.

Mild pallor, no icterus ,clubbing, cyanosis and generalised lymphadenopathy

Bilateral pedal edema

Vitals

Temperature: Afebrile 

Pulse rate: 86bpm

Respiratory rate: 18cpm

Blood pressure:140/80mmHg

Systemic examination:

Per abdomen:

On Inspection abdomen is not distended, umbilcus is present centrally and inverted. Scars are present. There are no engorged veins. All 9 regions of abdomen are equally moving with respiration. Hernial orifices are free

On palpation abdomen is soft , non tender and no organomegaly. All inspectory findings are confirmed.

On percussion: no shifting dullness, no fluid thrill

On auscultation: normal bowel sounds are heard.

Respiratory system:

On Inspection: 

Shape of the chest is elliptical 

Bilaterally symmetrical movements on respiration  

On Palpation:

Trachea is central

Expansion of chest is symmetrical.

On Auscultation:

B/L air entry present . Normal vesicular breath sounds heard 

Cardiovascular system

On Inspection : 

Shape of chest is elliptical 

No engorged veins, scars, visible pulsations

No raised JVP. 

On Palpation : Apex beat can be palpable in 5th inter costal space medial to mid clavicular line.

On Auscultation : S1,S2 are heard ,no murmurs.

Central nervous system:

Conscious, oriented to time place and person.

GCS on the day of admission  was E4 V5 M6

speech : normal

Behaviour : normal 

Memory : Immediate memory is slightly impaired recent and remote memory are normal

No hallucinations or delusions

Cranial nerve examination:

CN1: Normal

CN2: normal

CN3,4,6: normal

CN5: sensory intact

CN7:no abnormality noted

CN8: No abnormality noted.

CN9,10: palatal movements present and equal.

CN11,12: normal.

Motor system examination 

Bulk: normal

Tone: normal

Power:

                                Rightside    Left side

Upper limb           5/5                5/5

Lower limb           5/5                5/5

Superficial reflexes are present 

Deep tendon reflexes

                          Right                       Left

Biceps                  2                            2

Triceps                 2                            2

Supinator             2                           2

Knee                    2                             2

Ankle                   1                              1

Sensory system: normal

Cerebellar signs: no

Investigations 

Haemogram

Hb 9.5gm/dl

Total count 11500cell/cumm

Neutrophils 91%

Lymphocytes 6%

Pcv 24.7vol%

Mcv 76 fl

MCHC 38.5%

RBC 3.25 millions/cumm

On 16/03/23

Hb 10.2gm/dl

Total count 13500cell/cumm

Neutrophils 80%

Lymphocytes 15%

Pcv 27.1vol%

Mcv 77fl

MCHC 37.6

RBC 3.52millions/cumm

Serum electrolytes 

On 12/03/23

Sodium - 118

Potassium -3.0

Chloride -72

On 13/03/23

Sodium - 120

Potassium -3.0

Chloride -75

On 14/03/23

Sodium - 119

Potassium -2.7

Chloride -78

On 15/03/23

Sodium-115

Potassium-4.0

Chloride-80

On 16/03/23

Sodium- 116

Potassium-4

Chloride-80

ABG

pH 7.5

Pco2 28.9

Po2 88.9

16/03/23

pH 7.49

Pco2 27.2

Po2 85.2

HCO3 21

Serum creatinine 

1.5mg/dl (0.9-1.3)

Blood urea

42mg/dl (12-42)

On 16/03/23

Blood urea 51mg/dl

Urinary electrolytes 

Sodium - 152mmol/l

Potassium -25mmol/l

Chloride -119mmol/l

Fasting blood sugars 

161mg/dl

Post lunch blood sugar

219mg/dl

Glycated Haemoglobin

HbA1c 7.2%

Serum Osmolality

263mOsm/kg (275-295)

Serum MAGNESIUM 

2.0mg/dl (1.8-2.9)

Serum PHOSPHORUS 

2.9mg/dl (2.5-4.5)

Serum CALCIUM 

9.0mg/dl (8.6-10.2)

LFT

ALP 212 (56-119)

Total proteins 4.8 (6.4-8.3)

Albumin 2.6(3.2-4.6)

Complete urine examination 

Albumin +++

Sugar ++

Chest XRay

ECG

Ultrasound 

Diagnosis 

Hypoosmolar hypervolemic hyponatremia acute kidney injury with Diabetes mellitus and Hypertension 

Treatment:

1. FLUID RESTRICTION

2. INJ. KCL 20mEq IN 100ML NS @ 20ml/hr

3. TAB. METFORMIN 500 MG PO/BD

4. TAB. GLIMIPERIDE 1MG PO/BD

5. TAB. TELMA 40 MG PO/BD

6. TAB. MET XL 25 MG PO/BD

7. VITALS MONITORING

8. GRBS MONITORING.

9.TAB. CILINDIPINE 10MG PO/BD

10. INPUT OUTPUT CHARTING 

11. SYRUP. POTCHLOR 15ML PO/TIDVIN 1 GLASS OF WATER

12. INJ. ZOFER 4 MG IV/SOS

13. INJ. PAN 40 MG IV/OD

14. TAB. ALDACTONE 50 MG PO/OD

15. TAB. GLICLAZIDE 40 MG PO/OD