70 year old female with uncontrolled sugars

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A 70 year old female, resident of vangamarthy, labourer by occupation came with 

C/o lower back ache since 4 days - non radiating, aggravated on doing work, relieved on lying down.

C/o pain abdomen - diffuse type, non radiating, not a/w nausea or vomitings.

C/o SOB grade 2-3 (according to NYHA classification) since 10 days. Not a/w orthopnea, PND.

C/o itching - diffuse type since 10 days.

C/o dry cough since 10 days.

HISTORY OF PRESENTING ILLNESS :

Patient was apparently asymptomatic 20 years back - when she had fever, went to local RMP where over a routine checkup, she was diagnosed with DM type 2.

2018:  5 years back then she observed a pea sized swelling in the neck which was 2x2 cms where she went to the hospital and was diagnosed with hypothyroidism - was on T. Thyronorm 125mcg. There was a gradual increase in size of swelling where she underwent ?total thyroidectomy (2019)

K/c/o DM type 2 since 20 years. - on T. Glimi M1

No c/o pedal edema, decreased urine output, burning micturition, fever.

ON EXAMINATION :

Patient is C/C/C

Afebrile

BP : 130/80 mm hg

PR : 94 bpm, regular, normal volume

Spo2 : 97% under RA

GRBS : Hi

CVS : S1 S2 +, Apex beat : 5th ICS mid clavicular line.

RS : BAE +, No crepts 

CNS : NAD

P/A : Soft, no tenderness . Bowel sounds +

Pallor +

No icterus, cyanosis, clubbing or lymphadenopathy.

PROVISIONAL DIAGNOSIS:

? DKA

? Uncontrolled sugars with k/c/o DM type 2 since 20 years

S/P : Total thyroidectomy 4 years back

INVESTIGATIONS :

CBP -

Hb : 9.9  g/dl

TLC : 12300 

N : 65

L : 20 

E : 10

PCV : 27.8

MCV : 80.3

MCH : 28.6

MCHC : 35.6

Plt : 3.7 l

LFT -

Tb : 0.70

DB : 0.20

AST : 14

ALT : 13

ALP : 141

Total proteins : 5.4

Albumin : 3.2

A/G : 1.51

Serum creatinine : 1.0

Na+ : 131

K+ : 3.4

Cl- : 98

Magnesium : 1.8 mg/dl

ABG -

Ph : 7.38

Pco2 : 24.6

Po2 : 83.1

HCO 3 : 14.5 stat : 17.3

RBS : 454 mg/dl

Blood urea : 49 mg/dl

CUE : 

Sugars +++

Urine for ketone bodies -ve

LDH : 243 IU/L

Serum Iron : 95 ug/dl

HbA1c : 7.6

Phosphorus : 2.8

Chest X-ray

ECG

FINAL DIAGNOSIS :

UNCONTROLLED SUGARS WITH S/P TOTAL THYROIDECTOMY 4 YEARS BACK.

K/C/O HYPOTHYROIDISM

K/C/O DM TYPE 2

PLAN OF TREATMENT :

Inj. HAI pre meal 

8:00 AM /2:00 PM /8:00 PM

GRBS 7 point profile monitoring

SOAP NOTES Day 1

S- NO FRESH COMPLAINTS

O- PATIENT IS CONCIOUS, COHERENT, COOPERATIVE.

PALOR +

 NO ICTERUS, CLUBBING, CYANOSIS, LYMPHADENOPATHY.

VITALS :

TEMPERATURE - 98 F

PULSE RATE - 87  BPM, REGULAR, NORMAL VOLUME

BLOOD PRESSURE - 120/ 80MM OF HG

SPO2 - 98% AT RA

GRBS - 216 mg/dl

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED,SOFT NON-TENDER,NO GAURDING/RIGIDITY

CVS : S1 S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT,NORMAL VESICULAR BREATH SOUNDS

CNS : NAD

GRBS : on 2/4/22

8 pm : 218 mg/dl (given 10 units of insulin)

10 pm : 151 mg/dl

On 3/4/22

2 am : 184 mg/dl

6 am : 204 mg/dl

8 am : 216 mg/dl( given 12 units of insulin)

A - UNCONTROLLED SUGARS .

S/P .TOTAL THYROIDECTOMY WITH K/C/O . HYPOTHYROID  SINCE  5 YEARS. K/C/O DIABETES SINCE 20 YEARS

P - GRBS 7 POINT PROFILE MONITORING. 

SOAP NOTES Day 2

S- No fresh complaints

O- Patient is consious, coherent, co-operative.

Pallor +

No icterus, cyanosis, clubbing, lymphadenopathy.

VITALS :

Temperature - 98 F

Pulse rate - 76 BPM, REGULAR, NORMAL VOLUME

BP - 130/ 80MM OF HG

SPo2 - 98% AT RA

GRBS - 286 mg/dl

SYSTEMIC EXAMINATION - 

P/A : Non distended, soft, non tender. No guarding or rigidity.

CVS : S1 S2 heard , no murmurs

RS : BAE +, NVBS 

CNS : NAD

GRBS : on 3/4/22

10 am : 244 mg/dl

2 pm : 294 mg/dl (given 14 units HAI)

6 pm : 195 mg/dl

8 pm : 100 mg/dl (given 6 units of insulin)

10 pm : 134 mg/dl

On 3/4/22

2 am : 156 mg/dl

8 am : 286 mg/dl

A - UNCONTROLLED SUGARS .

S/P TOTAL THYROIDECTOMY WITH K/C/O HYPOTHYROID  SINCE  5 YEARS, K/C/O DIABETES SINCE 20 YEARS

P - GRBS 7 point GRBS monitoring 

SOAP NOTES Day 3

S- No fresh complaints

O- Patient is consious, coherent, co-operative.

Pallor +

No icterus, cyanosis, clubbing, lymphadenopathy.

VITALS :

Temperature - 98 F

Pulse rate - 79 BPM, REGULAR, NORMAL VOLUME

BP - 110/ 80MM OF HG

SPo2 - 98% AT RA

GRBS - 246 mg/dl

SYSTEMIC EXAMINATION - 

P/A : Non distended, soft, non tender. No guarding or rigidity.

CVS : S1 S2 heard , no murmurs

RS : BAE +, NVBS 

CNS : NAD

GRBS : on 4/4/22

4 pm : 340 mg/dl 

8 pm : 369 mg/dl

10 pm : 372 mg/dl

On 5/4/22

12 am : 82

2 am : 64

4 am : 54

7 am : 229

A - UNCONTROLLED SUGARS .

S/P TOTAL THYROIDECTOMY WITH K/C/O HYPOTHYROID  SINCE  5 YEARS, K/C/O DIABETES SINCE 20 YEARS

P - GRBS 2 hrly monitoring

SOAP NOTES Day 4

S- No fresh complaints

O- Patient is consious, coherent, co-operative.

Pallor +

No icterus, cyanosis, clubbing, lymphadenopathy.

VITALS :

Temperature - 98 F

Pulse rate - 79 BPM, REGULAR, NORMAL VOLUME

BP - 110/ 80MM OF HG

SPo2 - 98% AT RA

GRBS - 246 mg/dl

SYSTEMIC EXAMINATION - 

P/A : Non distended, soft, non tender. No guarding or rigidity.

CVS : S1 S2 heard , no murmurs

RS : BAE +, NVBS 

CNS : NAD

GRBS : on 5/4/22

10 am : 364 mg/dl

2 pm : 325 mg/dl 

6 pm : 325 mg/dl

10 pm : 342 mg/dl

A - UNCONTROLLED SUGARS .

S/P TOTAL THYROIDECTOMY WITH K/C/O HYPOTHYROID  SINCE  5 YEARS, K/C/O DIABETES SINCE 20 YEARS

P - GRBS 2 hrly monitoring