OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: CALUPAS, RAMON Hospital #: 1711174 Age/Sex: 80/M Address: Balingkit St. Leveriza Manila Date of admission: July 18,2007 Admitting Diagnosis: Hypoglycemia secondary to poor oral intake, DM type 2, CKD stage 4 secondary to DM Nephropathy, CAD, HCVD, LVH, AF with MVR, IIB Residents in charge: Drs. Delos Reyes/Filio/Indon Intern-in-Chage: PGI Velasco Clerk-in-Charge: Navarro/Ponelas/Reyes
CLINICAL ABSTRACT This is a case of an 80-yo male from Malate Manila who came in due to unresponsiveness. History of Present Illness Patient is a diagnosed case of DM type II 20 years ago, presently maintained on insulin 70/30 26 ‘u” in the morning; 16 ‘u’ in the evening. Patient was apparently well until… Three days prior to admission he had decreased appetite, with generalized body weakness. There were no chest pain, cough, dyspnea, colds and fever. He was still on insulin (usual dose). One day prior to admission, he still has decreased appetite and generalized body weakness. Still no chest pain, cough, dyspnea, colds and fever. Increase in sleeping time was noted. Usual dose on insulin is administered. Two hours prior to admission, he was unresponsive to verbal stimuli, and persistence prompted consult, hence the admission Past Medical History He is hypertensive, on unrecalled maintenance medications with good compliance; S/P CVD— 1990’s with residual. Usual and highest blood pressure unrecalled. (+) Osteoarthritis Right Knee; No allergy; No previous operation. Family History Has hypertension and diabetes mellitus on maternal side Personal and Social History Previous alcoholic beverage drinker; Previous smoker (?) pack years. Review of Systems General: weight loss (?), (-) fever, (-) anorexia HEENT: (+) blurring of vision, no headache, (+) dizziness, no epistaxis, no dysphagia Gastrointestinal: (-) abdominal pain, (-) vomiting, (-) bloody stool, (-) LBM Neurologic: (-) seizure, (-) loss of consciousness Urinary: no dysuria, no oliguria Endocrinology: (+) polyuria, (-) polyphagia, (-) polydipsia Physical Examination: Conscious, coherent, not in cardio-respiratory distress Vital Signs: BP: 120/80 HR: 78 RR: 20
HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, (-) distended neck veins CHEST AND LUNGS: symmetrical chest expansion, no retraction, (-) crackles, (-) wheezes HEART: adynamic precordium, PMI at 6th LICS, normal rate, regular rhythm, no murmur ABDOMEN: flabby, normoactive bowel sound, soft, non-tender EXTREMITIES: grossly normal, (+) discoloration on bilateral foot, (+) tenderness on right knee, (+) pain on active and passive movement, with full and equal pulses
Neurological Examination: Oriented to time, place and person CNI: can smell CNII: can count finger CNIII, IV, VI: Intact EOMS CN V: Positive corneal reflex, intact sensory V1-V3, can chew CNVII: No facial asymmetry CNVIII: follows commands CN IX, X: good gag reflex CN XI: can shrug shoulders CNXII: tongue at midline Negative Babinski, Negative Clonus, Negative Kernigs test, Negative Brudzinski test 5/5 (+) Knee pain 5/5 5/5 100% ? 100% 100% ++ ++ ++ ++
Assessment: Hypoglycemia secondary to poor oral intake DM type 2 CKD stage 4 secondary to DM Nephropathy CAD, HCVD, LVH, AF with MVR, IIB PLAN: Low salt, low fat, low protein diet, with SAP Maintain IVF For ABGs; spot urine K determination For UTZ KUB Medications: KCl 2 tabs TID, PO Moderate to high back rest Vital signs, neuro vital signs every 2 hours, CBG every 2 hours.