A 55 year old female patient with diagnosed diabetic ketoacidosis, nausea and bilateral UL & LL edema accompanied by facial puffiness - GM CASE 12
6th June 2023
CASE STUDY 12
Hello, I am Saloni .S. Gangotri , a 5th semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.
CASE SHEET:
CHIEF COMPLAINTS:
c/o
- Bilateral edema of both UL & LL since the past 10 days
- Nausea since 1 week.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10 days ago until she developed swelling bilaterally on both UL & LL which was treated by medication by a local practitioner in Nalgonda in 5 days. 1 week ago, she complained of nausea and was brought to OPD. She has had one episode of vomiting after consumption of food which was non projectile, non bilious and contained food contents. She was administered 2500mL (IV) of saline (0.95%NaCl) on 4th June out which she urinated 1300mL.
on 5th June she was administered 1600mL saline (100mL oral & 1500mL IV) out of which she urinated 700mL. She has been on saline intake since 3rd of June and resumed eating solid food on the morning of 6th of June. She gave a history of rash on her forearms and arms 1 month back which healed spontaneously. She also has a history of osteoarthritis since 6 years for which she was prescribed pain killers and NSAIDs for a short period of time but continued to consume it everyday to relieve the pain. On examination she was also diagnosed with Diabetic ketoacidosis.
h/o burning micturition and itching in vaginal area 10 days ago.
h/o nausea since 7 days.
h/o rash in forearms and arms.
h/o 1 episode of vomiting after intake of food which was non projectile, non bilious and contained food contents.
no h/o fever
no h/o constipation
no h/o diarrhea
ASSOCIATED DISEASES:
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PAST HISTORY:
h/o HTN since 5 years and is on medication.
h/o DM on examination.
No K/C/O Epilepsy, TB, CAD, CKD.
PERSONAL HISTORY:
Married.
Is on a mixed diet.
Reduced appetite.
Inadequate sleep.
Regular Bowel movements.
Has no known allergies.
Was a chronic alcoholic and consumed tobacco everyday 35 years ago.
FAMILY HISTORY:
h/o mother having breast cancer.
h/o brother having heart attack.
Has N/K/C/O Diabetes Mellitus, No HTN, No Strokes. No CAD, TB, Asthma or Epilepsy.
DRUG HISTORY:
GENERAL EXAMINATION:
-No palor
-No Icterus
-No cyanosis
-No lymphadenopathy
-pedal edema present
-edema of upper limbs present
-facial puffiness present
-No clubbing of fingers
VITALS:
Temperature: Febrile - 98.7°F
Pulse: 106 beats per minute
Respiratory rate: —22 cycles per minute
Blood pressure: 120/80 mm of Hg
SPO²: 98%
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 present
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular? yes
Abdomen:
Shape : Obese
No tenderness
No palpable mass
non palpable spleen
hernial orifices normal
Non palpable liver
No free fluid (ascites) present
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious and Alert
Speech: Normal
INVESTIGATIONS:
Biochemical investigations:
ECG:
2D-ECHO REPORT:
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ULTRASOUND REPORT:
GRAPHIC SHEET :
PROVISIONAL DIAGNOSIS:
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