50 yr old male with uncontrolled sugars
I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan
NAME:- G VISHAL
ROLL NO :- 50
This is a case of 50 years old male resident of nalgonda daily wage worker by occupation and came to the casualty with sudden fall and loss of consciousness on 27/12/22
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 7 days ago and then he developed loss of consciousness during his work which was sudden in onset and is not ass with any aura and seizure activity.
No up rolling of eye lids and frothing.
H/o blurring of vision since 4 months
H/o nocturia, polyuria and dysuria since 2 months
H/o tingling sensation in the leg occasionally.
H/o dry cough intermittently since 10 days
No h/o buring micturation,sob and pedal edema no h/o palpitations
No h/o fever ,nausea and vomiting.
SEQUENCE OF EVENTS:
10 years back he was diagnosed with type 2 diabetes mellitus and was on oral hypoglycemic agents but did not have any dietary modifications due of lack of awareness.
6 months back he was diagnosed with hypertension but he took medication for 15 days and then stopped using medication.1 month back he was diagnosed with ckd and stones as he was having back ache.for which medication were given.
Since 1 month he shifted to insulin from oral hypoglycemic agents.
7 days back he didn't take insulin and went to work where he suddenly had loss of consciousness and was bought to hsptl in nalgonda and was reffered to our hsptl on 27/12/22 afternoon.
PAST HISTORY: No similar complaints in the past.
No h/o asthma, tb ,epilepsy thyroid abnormalities and blood transfusions.
No h/o previous surgeries.
PERSONAL HISTORY:
DIET: mixed diet
Apetite: normal
Bowel: normal
Bladder: polyuria,nocturia and dysuria
Sleep: adequate
Addictions: smoker since 35 years used to smoke 2 packets daily( beedi) but reduced to 2 beedis per day since 1 month
Occasionally takes alcohol.
Family history:
H/o diabetes to mother and died with hyperglycaemia
DRUG HISTORY:
Not significant
GENERAL EXAMINATION:
Patient is conscious ,coherant,cooperative.moderatly built and moderatly nourished.
No pallor,icterus ,clubbing, cyanosis and bilateral pedal edema.
Temperature ; afebrile
RR;16cycles/min
PULSE;70bpm
GRBS;240mg/dl
Spo2; 100 at room temperature
BP; 170/90 mm of hg
SYSTEMIC EXAMINATION;
Cardiovascular system- Inspection :
Shape of chest- elliptical shaped chest
No engorged veins, scars, visible pulsations
No raised JVP.
Palpation : Apex beat can be palpable in 5th inter costal space medial to mid clavicular line.No thrills and parasternal heaves can be felt
Auscultation : S1,S2 are heard ,no murmurs.
Respiratory system:
bilateral air entry present ; no abnormal air sounds heard
Central nervous system- Conscious, oriented to time place and person.
GCS on the day of admission was E1 V2 M4
MOTOR SYSTEM EXAMINATION
Bulk of the muscle: normal
Tone of muscle : normal
POWER -
RT. LT
Upper limb 5/5. 5/5
Lower limb 5/5. 5/5
DEEP TENDON REFLEXES :
BP TRI SUP KNEE ANK PLAN
RT ++ + + ++ ++ ++ Flex
LT ++ ++ ++ ++ ++ Flex
CEREBELLAR SIGNS : no
Meningeal signs: no
Abdominal examination :
Inspection:on inspection abdomen is flat, symetrical,and not distended.umbilcus is centre and inverted.no scars,engorged veins are seen.All 9 regions of abdomen are equally moving with respiration.all hernial orfices are clear.
Palpation:abdomen is soft , no tenderness no other palpable organs are felt.On bimanual examination of kidney is not palpable.All inspectory findings are confirmed.
percussion:no shifting dullness, no fluid thrills.
auscultation:normal bowel sounds are heard.
PROVISIONAL DIAGNOSIS: uncontrolled diabetes mellitus due to non compliance of treatment.
INVESTIGATIONS:
Hb: 4.6 g/dl
Sr.creat:4.2
Blood urea :90
HBA1C:7.5
FBS 295 gm/dl
LIPID PROFILE:
TGL:182
HDL 56
LDL 115
VLDL 36
USG ABDOMEN REPORT:
Diagnosis:
Altered sensorium secondary to hyperosmolar Hyperglycemic state.
Hypertensive urgency with severe Uncontrolled hypertension with AKI on CKD
TREATMENT:
1 inj HAR 12units tid
2 iv fluids
3 Inj PAN 40 mg /IV/OD
4 Inj Thiamine 200 mg /100 ml NS IV/BDAYY
5Inj monocef 1gm/IV /BD
6Serum potassium every 6 hrly
7 Vitals monitoring every 4 hrly and GRBS hrly monitoring
8 Inj 10%dextrose 30 ml/hr/IV
9 Tab amlong 5mg /RT /OD
10Inj levipril 1gm /IV/Stat to
11 Inj levipril 500 mg in 100 ml NS/IV/B
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