Pranati V (roll no. 129): 60/f with altered sensorium 2° hyponatremia

C/o generalised weakness since 2 months

Body pain (+)

C/o pain abdomen since 8 days

Patient is a diabetic since 20 years initially on OHA later shifted to insulin Mixtard (30/70) since 1 week because of high sugars .

She was apparently assymoptomatic 2 months back ,then she used to complaint of generalised body pains and weakness .

No fever ,no vomitings ,no loose stools.

Since 8 days patient is complaining of pain abdomen - diffuse , intermittently

No vomitings ,no loose stools .

For the above complaints she was taken to RMP and got symptomatic treatment ,but found to have high sugars ,so they visited local doctor in nalgonda ,where her previous OHA was changed to Insulin.

Now she presented to us with complaints of

Decreased urine output

Pedal edema , abdominal distension since 3 days .

With decreased food intake ,droswiness

Constipation since 2 days

H/o usage of T. aceclofenac 100mg po od since 3 days

Pt is a k/c/o DM-TYPE2 since 20 years, initially on OHA, since 20 days is on Human Mixtard Insulin (30/70) (30u--x--30u)

N/k/c/o htn, TB, BA, CAD, CVA,thyroid disorders

O/e

BP- 120/70mmhg

Pr- 81 BPM

RR- 16cpm

TEMP- afebrile

GRBS-319mg/dl

No pallor, icterus, cyanosis clubbing lymphedema. Edema of feet present (grade 2)

CVS- S1 S2 heard

Rs- BAE (+) crepts in left IAA, IMA heard

P/A- soft, distended, umbilicus transversly split, diffuse tenderness

CNS- altered, not oriented to t/p/p

Provisional diagnosis- anasarca

Uncontrolled blood sugars

AKI

Diagnosis-

Altered sensorium 2° to hyponatremia with AKI with ? hepatitis with right renal calculi

With DM-type 2 with uncontrolled sugars

Rx-

IVF- ns, RL up+ 50ml/hr

Inj. Lasix 40mg iv bd

Inj. 3% NaCl @20ml/hr

Inj. Pan 40mg iv od

Inj. ZOFER 4mg iv SOS

Inj. Tramadol 1amp in 100ml NS IV/tid

Inj. Neomol 1gm iv SOS

T. PCM 500mg po/sos

I/o charting

Vitals monitoring

GRBS- 7 Point profile

Soap notes (1/1/22)

S-

O- BP- 110/70mmhg

Pr- 78 BPM