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Case history:
55 Year old lady alleged to have a history of slip and fall in bathroom 3days ago,
And complained of left knee pain since fall,got treated with slab immobilisation at local hospital and came for further management.
Burning micturition- present
No history of head injury,loss of consciousness, ENT bleed and vomiting.
No history of chest pain, palpitations,pedal edema, fever,cough, decreased urine output, blurring of vision, polyuria,polydipsia.
Past history-
She is a known case of DM-2 since 30yrs, HTN Since 4yrs and CAD Since 4yrs .
no history of TB, asthma, epilepsy.
Personal history-
Diet-mixed
Appetite-normal
Bowel and bladder-regular
No Addictions.
Surgical history-
Valvular surgery done 4yrs ago.
Treatment history-
Unknown medication for hypertension.
She is on GLIPIZIDE-5mg,METFORMIN- 500mg BD
On ECOSPIRIN 75MG OD,ATORVASTATIN-20MG.
General examination-
Patient is conscious, coherent and cooperative.
Vitals- afebrile to touch
Bp-140/100mmhg
Pulse-88bpm, regular, normal volume
Spo2-99%
Grbs-128mg/dl
CVS-S1S2 heard,no murmurs.
Respiratory system-BLAE- present
PCT-negative
CCT-negative
Per abdomen-soft, nontender
CNS-speech -normal
motor and sensorysystem- normal
Reflexes- R. L.
Biceps- 2+. 2+.
Triceps-. 2+. 2+.
Supinator-. 2+. 2+.
Knee-. 2+.
Ankle-. 1+. 1+.
Cerebellar functions-Normal
Provisional diagnosis-
Left patellar fracture
Case was referred to medicine in view of DM-2,HTN and CAD.
Investigations-
ECG-
Regular,axis-normal,LVH- present.
RBS-116Mg/dl
Pt-15sec
INR-1.11
APTT-30Sec
BT-2min 30 sec,CT-4min 30 sec
Blood grouping and rh typing-B positive
CBP-
HB-10.5gm/dl
TC-5500cells/cumm
Platelets-1.5 lakhs/cumm
LFT-
Total bilirubin-0.50mg/dl
Direct bilirubin-0.14mg/dl
AST-11 IU/L
ALT-16 IU/L
ALP-177 IU/L
Total proteins-5.9gm/dl
Albumin-3.3gm/dl
A/G ratio- 1.32
RFT-
urea-36mg/dl
Creatinine-1.1mg/dl
Uric acid-5.4mg/dl
Calcium-9.7mg/dl
Sodium-140mEq/l
Potassium-3.1mEq/l
Chloride-96mEq/l
2D ECHO-trivial AR+/MR+,No TR,No RWMA,sclerotic AV,No AS/MS,good LV systolic function,no diastolic dysfunction,No PAH/PE.
Treatment given-
1.strict diabetic and salt restricted diet
2.tab.TELMA 40 mg/po/OD
3.tab.GLIPIZIDE 5mg BD
tab.METFORMIN 500 mg BD
4.tab.ECOSPIRIN AV gold H/s
5.bp/pr/ump charting 4th hrly
6.inform SOS
7.GRBS charting
8.Syp.POTCHLOR 10ml/in one glass of waterBD.
9.tab.clopitab 75mg.
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