desembrana-48 by dredwardmark

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									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Desembrana, Flaviana Age/Sex: 70/F Address: 2080 F. Munoz St. San Andres Manila Date of admission: August 30, 2007 Admitting Diagnosis: Hypoglycemia Prob Secondary to OHA DM Type II HCVD CAD NSR II-B Final Diagnosis: Hypoglycemia Prob Secondary to OHA DM Type II HCVD CAD NSR II-B Residents in charge: Drs.Dalanon/Gutierrez/Gregorio CIC: Palay/Rentillo/Roxas

Hospital #: 1523867

24 hour history This is a case of a 70 year-old female who came in to IM-ER due to unresponsiveness. History of Present Illness Patient is a case of DM type II and was maintained on Metformin 500 mg OD and Glimeperide 3 g 1 tab OD previously with good compliance. Patient was apparently well until… 3 days PTA, patient had headache, generalized, dull throbbing not associated with dizziness and vomiting. BP taken was 200/100. she was given Nifedifine SL which did not resolve the headache and was not able to lower the BP. She sought consult complete at FM-ER then was referred to IM-ER for further evaluation and management. Dx: DM type II; HCVD, CAD, NSR, II-B. patient was sent home eventually with ff meds: Simvastatin 20mg OD, Glimeperide 3 g OD, Metformin 500 mg BID, Amlodipine 10mg OD, Bipeterax 1 tab OD Meloxicam PRN for joint pain with good compliance. 2 days PTA, patient had decreased oral food intake, with generalized body weakness and headache. No vomiting was noted. BP was still at 180-190/100. no other associated symptoms. No fever, cough or colds. Patient was compliant with the medications given. 1 day PTA, there was persistence of above symptoms. There was progressive decreased in oral food intake. Few hours PTA, patient was noted to be sleeping most of the time. There was twitching of face and inability to recognize familiar faces. Soon patient was unresponsive to verbal stimuli. No chest pain, seizure or loss of consciousness was noted. Persistence of these symptoms prompted consult to OMMC. At the ER, CBG of the patient was 40mg/dl. Patient was subsequently admitted. Past Medical History (+) DM >20 years (+) HPN for 15 years HBP- 200/100 (-) asthma

UBP- 180/90 meds: Amlodipine and Nifedipine with poor compliance.

Family History (+) DM- maternal side (-) HPN Patient denies other heredofamilial disease. Personal and Social History Nonsmoker and nonalcoholic beverage drinker Review of Systems General: no weight loss, no anorexia HEENT: blurring of vision, no tinnitus, no dysphagia Respiratory: no cough, no hemoptysis, no difficulty of breathing Cardio: (+) easy fatigability, (-) orthopnea (-) PND GIT: No abdominal pain, no change of bowel movement GUT: no nocturia,(-) dysuria, (-) hematuria Endocrine: no polyuria no polydipsia no polyphagia Physical Examination: Patient was comatose then became conscious, not in cardiorespiratory distress Vital Signs: BP: 140/90 HR: 92 RR:20 Temp: 36.7oC HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, CHEST AND LUNGS: symmetrical chest expansion, no retraction, clear breath sounds HEART: adynamic precordium, NRRR, PMI heard at 6th lICS AAL, no murmur ABDOMEN: flabby, NABS, soft, non-tender EXTREMITIES: (+) pain on passive and active extension of left knee (-) tophi, (-) edema NEURO: Patient was comatose then became awake and oriented. Cranial Nerves: I – can smell II – can read II, III– pupils equally reactive to light and accommodation, 3 – 4 mm III, IV, VI – intact EOM V – (+) bicorneal reflex, intact V1 – V3 VII – no facial asymmetry VIII – intact gross hearing

IX, X – good gag XI – can shrug shoulders equally XII – tongue at midline upon protrusion Motor: 5/5 5/5 5/5 5/5 Sensory: 100% 100% 100% 100% Reflex: ++ ++ ++ ++

No Babinski, Kernig’s, Brudzinski Assessment: Hypoglycemia Prob Secondary to OHA DM Type II HCVD CAD NSR II-B Course in the Ward: Patient was admitted at IM-Infirmary ward. Consent for admission and management was secured. Input and Output monitored every shift, patient placed on DM diet with SAP. IVF: D10 water 1L x 12 hours. Input and Output monitoring, TPR q shift, Diagnostics requested were RBS every 4 hours, 12 lead ECG, CBC c PC, urinalysis, CXR- PA, FBS, BUN, Crea, Na, K, Ca, Mg, Cholesterol, TG, HDL, LDL,BUA, HgBA1C, KUB-UTZ. Therapeutics given was: 1. ASA 80 mg tab 4 tabs chewed and swallowed then OD PO 2. Simvastatin 40 mg tab OD PO 3. amlodipine 10 mg tab OD PO 4. Nifedipine 10 mg cap PO for BP >160/100 5. imidapril + HCTZ 10 mg tab OD PO Vital signs monitored every hour, NVS/GCS q1. CBG q6, moderate to high back rest. On the 1st HD, patient was on DM diet with SAP. IVF: D10W 1 L X 12 hours. Therapeutics given was continued. Regular insulin was given PRN if CBG>250mg/dl and D50-50 ml < 60 mg/dl. Vital signs were as follows: 160/90 CR68 RR18 T 36.9C. On the 2nd hospital day, vital signs were as follows: BP150/90 CR89 RR18 afebrile. she was on DM diet with SAP. IVF: D10W 1 L X 12 hours. Therapeutics given was continued. RBS was 160mg/dL. She was conscious and coherent. On the 3rd hospital day, patient was on DM diet with SAP. IVF: D10W 1 L X 12 hours. Therapeutics given was continued. Vital signs were stable and the patient is normoglycemic. On the 4th hospital day, patient was discharged with the ff home meds: 1. ASA 80 mg tab 4 tabs chewed and swallowed then OD PO 2. Simvastatin 40 mg tab OD PO 3. Imidapril + HCTZ 10 mg tab OD PO 4. Captopril 25 mg/tab SL PRN for BP>160/90 5. MV + Buclizine Tab OD Plan: for referral to rehabilitative medicine re: generalized body conditioning Laboratory Results: X-RAY (08/24/07) CXR- Magnified Cardiac Shadows ECG (08/24/07) Left Axis Deviation Complete Blood Count Normal Values WBC 4.8-10.8 x 109 /L RBC 4.0-6.20 x 1012 /L Hgb 12-16g/dl Hct 37-47 % MCV 80-90 fL MCH 27-31 MCHC 32-36 Platelet 150-400 x 10^9/L Neutrophils 55-57 Lymphocytes 20-30% Monocytes 0-7% Eosinophils 0-3% Basophils 0-1%

Aug 24 3.6 3.7 10.5 30.5 81.5 28.1 35 222 62.6 30.6 5.7 1.1 0

Blood Chemistry BUN Creatinine Uric Acid Glucose FBS Cholesterol Triglyceride Normal Values 2.5 - 7.10 mmol/L 53 – 115 umol/L 178 – 345 umol/L 3.9 – 6.4 mmol/L 3.89 – 5.84 mmol/L 3.8 – 6.1 mmol/L 0.4 – 2.26 mmol/L Aug 25 23.90 297 Aug 26

3.06 5.80 2.06

HDL LDL HDL Ratio VLDL AST ALT Total Protein Albumin S. Globulin Sodium Potassium Chloride Calcium Magnesium CPK-MB HgBA1C

0.67 – 1.94 mmol/L 1.32 – 2.52 mmol/L 0–4 0.21 – 0.86 mmol/L 10 – 31 U/L 9 – 36 U/L 66 – 87 g/L 34-48 g/dL 20 – 38 g/L 140-148 mmol/L 3.6 – 5.2 100-108 mmol/L 2.12 – 2.62 mmol/L 0.65- 1.03 mmol/L 0.00-24.00 4.20-6.20%

0.82 4.0

138 4.0 103 2.12 0.89

135 3.6

6.6

Urinalysis Color Transparency Epithelial Cells Mucus Threads Amorphous Urates Pus Cells Erythrocytes Cast Albumin Sugar SG pH Bacteria Calcium Oxalate Aug 24 Yellow Turbid Many Few Few Many 0-2 +++ Negative 1.030 6.0


								
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