Case Discussion


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A 58 Y/O Female with NSTEMI and uncontrolled sugars

 CHIEF COMPLAINTS

A 58y/o female came to the casuality with the chief complaints of:
  • Sudden onset chest pain
  • Giddiness
  • Profuse sweating 

HISTORY OF PRESENTING ILLNESS

  • The patient was apparently asymptomatic in the morning. Then later that evening she had 1 episode of chest pain associated with giddiness and profuse sweating at 6:00 PM on 08/09/21.
  • The chest pain is throbbing type in the epigastric region with giddiness, sweating.
  • This episode was associated with 1 episode of vomiting that was non bilious, non projectile, with food as the content, not associated with palpitations, blackouts, blurring of vision, diplopia, headache, neck pain. 
  • The patient went to local RMP with the same complaints. There her GRBS was 446mg/dl for which Tab Metformin 500mg was given and the patient was referred to our hospital for further management. 
  • On presentation to our OPD, her Temperature was Afebrile, Blood Pressure was 120/70mmHg, Pulse Rate was 78bpm, Respiratory rate was 12cpm, SpO2 was 96% and GRBS 336

PAST HISTORY

  • The patient was apparently symptomatic 4 years ago. Then she had an episode of altered sensorium, she had no orientation of time, place and person for 1 day and was diagnosed with HTN and Type 2 DM in our hospital. 
  • MRI Brain had shown an Acute infarct in Right lentiform nucleus and internal capsule
  • USG Abdomen had shown Grade 1 fatty liver 
  • Carotid Doppler had shown Atherosclerotic changes in B/L carotid arteries 
  • K/C/O DM since 4 years Tab Glimi 0.5mg and Tab Metformin 500mg OD 
  • K/C/O HTN since 4 years Tab Telma 40mg. 

PERSONAL HISTORY

  • Reduced appetite 
  • Mixed diet 
  • Regular bowel and bladder movements 
  • No addictions

GENERAL EXMINATION
  • Patient is conscious, coherent and cooperative
  • Moderately built and nourished. 
  • Pallor Absent
  • Icterus Absent 
  • Cyanosis Absent 
  • Clubbing Absent 
  • Lymphadenopathy Absent 
  • Pedal edema Absent 

VITALS
  • Temperature: Afebrile
  • BP: 90/70 mmHg 
  • PR: 78 bpm
  • RR: 12 cpm 
  • SpO2: 96% 
  • GRBS: 336 mg/dL

SYSTEMIC EXAMINATION:
  • CVS: S1 & S2 heard, no cardiac murmurs
  • RS: normal vesicular breath sounds, trachea central, no dyspnea or wheezing 
  • P/A: shape obese, tenderness in the epigastric region, no palpable mass, bowel sounds heard
  • CNS: Patient is conscious, speech normal, GCS score 15/15 
  • Cranial nerves: normal 
  • Motor system: Normal 
  • Sensory system: Normal
  • Reflexes: R & L Biceps + + Triceps-- Supinator-- Knee3+ 3+ Ankle+ + 

INVESTIGATIONS:

RBS: 440MG/DL

HEMOGRAM: 
  • HB 9.2
  • TLC 13300
  • PCV 27
  • PLT 2.07 LAKH
CUE: 
  • ALB TRACE
  • SUGARS ++++
  • PUS CELLS 3-4
  • EPI CELLS 2-3
URINE ELECTROLYTES: 
  • NA 382, K 33.3
  • CL 488
BGT: A+

ECG BEDSIDE:

LFT TB 1.04, BD 0.35, AST 37, ALT 19, ALB 3.7, ALP 279, PROT 6.4
RFT CR 1.0, UREA 33, NA 137, K 3.9, CL 102

Treatment Given: 
1. IVF NS AT 20ML/KG/HR
2. INJ OPTINEURON 1 AMP IN 100ML NS
3. INJ HAI 6 U ACTRAPID IV STAT
4. INJ PANTOP 40 MG IV STAT
5. TAB PCM 500MG PO TID
6. TAB ULTRACET 1/2 1/2 1/2 1/2
7. TAB ASPIRIN 325 MG
8. TAB CLOPITAB 300 MG
9. TAB ATORVAS 80 MG
10 GRBS MONITORING WITH INJ HAI INFUSION AT 8ML/HR
3 AM 559 MG/DL
4 AM 491 MG/DL
5 AM 409 MG/DL
6 AM 393 MG/DL
F/U:
Patient was discharged from the hospital on 09/09/21 at 6:30am and was referred to a higher centre.
The patient got admitted into another hospital. She presented with acute pulmonary edema, grade 4 dyspnoea, she got intubated in casuality. Then was shifted to the ICU after stabilisation Angio was done PTCA was placed. Then she got discharged.
Treating faculty: 
DR.KEERTHI.K(INTERN)
DR.HARIKA(INTERN)
DR.ROSHINI(INTERN)
DR.MOUNIKA(INTERN)
DR.MANASA(PGY1)
DR.ZAIN ALAM(PGY2)
DR.A.VAISHNAVI(PGY2)
DR.PRAVEEN NAIK( ASSOCIATE PROFESSOR)
DR.ARJUN (SR)
DR.RAKESH BISWAS(HOD)

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