SHORT CASE- 75 YRS OLD FEMALE WITH VOMITING AND GIDDINESS

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General Medicine Final Examination Short Case

Hall ticket- 1701006171

Sneha Chauhan 


FINALS SHORT CASE PRACTICAL CASE BLOG 


  • This is an online E-log to discuss our patient’s de-identified health data shared after taking his/her/guardian’s informed consent. 
  • Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. 
  • This E-log also reflects my patient centered online learning portfolio and your valuable inputs on comment box are welcome. 
  • I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competence in reading and comprehending clinical data including history, clinical findings and come up with diagnosis and treatment plan. 
  • The patient and the attenders have been adequately informed about the documentation and privacy of the patient. No identifiers shall be revealed throughout this presentation. 




A 75 years old female who is currently living alone came with chief complaints of-


Chief complaints-

  1. Vomiting since 1 day
  2. And Giddiness, since 1 day


History of Presenting illness- 


Patient has history of Diabetes and Hypertension since 5 years. She had visited her daughter 5 days ago, where she forgot to take her medications for the same, hence resulted in current presentation of Vomiting and giddiness for which she was brought to the causality. 

  1. Vomiting-
  • sudden in onset
  • 2-3 episodes
  • Non projectile,
  • Non bilious 
  • Associated with 


2. Giddiness- sudden in onset 


Her life before the acute presentation was very mellow. Since she was living on her own, she’d manage the house by herself by cooking, cleaning and looking after herself with the occasional visits from and to her children. 


No history of chest pain, palpitations, pain abdomen, shortness of breath etc.



Past History-

  • Hasn’t had similar complaints in the past
  • History of diabetes and hypertension. Was diagnosed as part of her profile follow up before her cataract surgery was done. During which time she had complaints of headache and generalised weakness as well then. 
  • No history of Asthma, Allergies, Tuberculosis, epilepsy.


Drug History- Antihypertensive (Clinidipine) and Oral Hypoglycemic (unknown)



Surgical history-

Had cataract surgery done on both eyes, one eye 5 years ago at the time of diagnosis of Hypertension and Diabetes mellitus and one done 2-3 yrs ago. 



Family History- insignificant 



Personal History-

Mixed diet

Decreased appetite since the time of admission 

Regular bowel and bladder 

Adequate sleep

No such addictions 



Menstrual history- Attained menopause almost 20 years ago 



General physical examination- 


  • well built and nourished 
  • Pallor- present 
  • No signs of icterus, cyanosis, clubbing, lymphadenopathy and edema
  • Vitals

Pulse rate- 72 beats per minute

Respiratory rate- 16 cycles per minute 

Temperature- Afebrile 

Blood pressure- 170/80 mmHg















Abdominal examination-

  • Inspection- shape of abdomen is scaphoid, no visible peristalsis 
  • Palpation- soft, non tender and no organomegaly
  • Percussion- no free fluid
  • Auscultation- bowel sounds heard. 







Respiratory examination-

  • examination of nose and oral cavity- appear normal
  • Inspection- 
  1. Shape of chest- bilaterally symmetrical
  2. Expansion of chest- appears equal on both sides
  3. No crowding of ribs
  4. No visible pulsation or engorgement 
  5. No visible scars or sinuses
  • Palpation of chest-
  1. No tenderness 
  2. No local rise of temperature 
  3. Expansion of chest equal on both sides 
  4. Apex beat- medial to mid clavicular line in the 5th intercostal space. 
  • Percussion-resonant on all areas 
  • Auscultation- Bilateral air entry, normal vesicular breath sounds. 

Cardiovascular system examination- 

  • Inspection- no visible pulsation 
  • Palpation- apex beat felt
  • Percussion- heart borders are normal
  • Auscultation- S1S2 heard, no added murmurs


Central nervous system examination- 

  • Conscious 
  • Normal speech 
  • Cranial nerves intact
  • Sensory and motor system- normal 
  • Neck stiffness- absent
  • Reflexes- normal

Diagnosis- Diabetic Ketoacidosis with Hypertensive Urgency



Investigations-

  • Electrolytes-

Potassium- 3.3 mEq/L

Sodium- 139 mEq/L

Chloride- 98 mEq/L


  • Urine positive for Ketone bodies and sugar (++++), pus cells and epithelial cells seen, no RBC casts.
  • Haemoglobin- 11.3 g/dl


Random blood sugar on 12/06/22- 285mg/dl





ECG- 





Treatment-

  1. IVF NS & RL (1000ml per hr)
  2. Inj INSULIN IV 
  3. inj ZOFER
  4. Tab TELMA
  5. monitor GRBS, BP, HR, RR 















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