50 year old female with recurrent hypoglycemia

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog 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 diagnosis and treatment plan.



50 yr old woman presented to casuality with c/o 
Loss of consciousness  since 30 min 
Recurrent episodes of LOC since yesterday morning 5 am
Fever since 1 month
Burning micturation since 2days
Facial puffiness 
Abdominal distensincd since 1 month
 B/L lower limb swelling since 1 month
 Lower back pain since 1 month Weight loss over the past 1 month. 

Patient works as a coolie. She has been lost her husband 2 years back in an accident, while he was repairing his truck, another truck ran over him. Since then she has been depressed.
15 years back she got diagnosed to be  a diabetic on routine check up and has been on medication TAB.GLIMISTAR M1, which she takes regularly. Prior to this she used to use Tab Glimi 1mg


 
 2 years back - She got diagnosed to be a hypertensive on routine check up and has been on T.TELMIKIND 40 mg OD 

2 years back-  got diagnosed with bilateral renal calculi and was on homeopathic medication for a few days

She has been experiencing fever on and off since 1month  and she also has been having facial puffiness , gradually she even developed abdominal distension along with B/L lower limbs swelling upto knees 

Day before yesterday morning: 

 At 5am patient had  - 1 episode of LOC which lasted for an hour
 1Am -  1 hour episode of LOC  

Yesterday morning at 5 am:  another episode for 1 hour  for which he visited local hospital and received 25%D 

For these Recurrent episodes of hypoglycemia she visited a local hospital, received IV fluids and went home 

Yesterday she presented to casualty at 3pm with  LOC since 1/2 hour and pt regained consciousness  after 25% D injection


On examination 
 Pt is conscious,coherent, cooperative 
Obese patient 
Pallor+
Facial puffiness with periorbital edema +
Bilateral pedal edema upto knees +
Koilonychia+

JVP not elevated

Vitals at the time of admission:
Temp-103°F
BP- 160/80 mm of hg
PR - 104 bpm
RR- 24 cycles/min
Spo2 - 99% at room air
GRBS - 20

 Systemic examination:
CVS: apex beat was difficult to appreciate since she is obese
 S1,S2 heard 
         
RS: B/L inspiratory crepts in IAA
Per abdomen : soft,non tender, no palpable masses


CNS: NAD

Provisional diagnosis;
Recurrent hypoglycemia secondary to OHAs
? Nephrotic syndrome 
Right heart failure 
Anemia under evaluation


Investigations 
 Her Hb is 6.2 
Tlc - 10,600
Platelet - 3.60 L/cumm

Albumin is 2.3
Cue shows no albumin and RBC loss
However her spot protein creatinine ratio is 1.78

Serum creatinine- 3.5
Blood urea is 59 
Urinary electrolytes -
Na - 164
K - 8.8
Cl - 213
ABG - 
Ph - 7.2
Pco2 - 17.1
Po2 - 89.2
Hco3- 10


Ultrasonography of abdomen showed no reduced size of Kidneys
Chest X ray

 Ecg

2D ECHO


Rx
1) Head end elevation
2) Maintain O2 Spo2>95%
3) Fluid restriction <1l/day
     Salt restriction <2g/day
4) Inj.PANTOP 40 MG IV OD
5) INJ.LASIX 40 MG IV BD
        8am-4pm
6) Inj.25% D if GRBS<75mg/dl
7) GRBS Monitoring hourly
8) Monitor vitals
9) I/O charting



Day 2
Rx
1) Head end elevation
2)O2 supplementation if spo2<95%
3) Inj.MONOCEF 1gm IV BD
4) Fluid restriction < 1lit/day
     Salt restriction  <2.4gm/day
5) Inj.PAN 40 MG IV OD
6) Inj.25%D if GRBS<75MG/do
7) GRBS monitoring hourly 
8) BP,PR,SPO2 2 hourly

Popular Posts