29 yr old male ot technician
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CASE. :
29/M OT technician working in a private hospital (Hyderabad) came to opd with C/o of
1)Froathy urine since 1 year
2)constipation since 5 months
3)Diminished vision since 1 month
4)Difficulty in deglutation ( liq more than solids) since 1 month
5)legpains and fever since 1 week
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 8 years back later he had polyuria, giddiness and sweating for 1 days then he visisted hospital in janagam routine investigations were done , then his RBS is 500 mg/dland was Started on inj mixtrad 25U -0- 25U and Inj HAI 20U -0- 20U
Later 1 yr back he started passing froathy urine but didn’t visit any hospital. He also suffered from constipation since 5 months
4 months back he developed pain abdomen( which is of squeezing type and diffuse all over the abdomen) and 5-6 Episodes of vomitings (non bilious and non projectile,with food particles as content) and also loose stools which lasted for 15 days, For which he took treatment
TAB.cefodaxime
TAB.Ofloxacin and
TAB.L-ornithine
Since 1 month he had diminision of vision in both eyes which was insidious in onset and slowly progressive in nature and also suffered with difficulty in deglutition (liquids more than solids )
Since 15 days pt experiences giddiness and headache even on walking for half a kilometre when he checked his grbs was 280 and bp is 120/80
Since 1 week pt was suffering from leg pains and low grade , continuos intermittent fever which was insidious in onset,progressive in nature ,not associated with chills and rigors,relieved on medication.
PAST HISTORY :
No history of similar complaints in the past.
Not a k/c/o of hypertension , diabetes,TB,epilepsy,asthma,CAD
No history of any surgeries or blood transfusions
PERSONAL HISTORY :
Marital status - unmarried
Sleep : adequate
Appetite : Mixed
Bowel movements : constipation since 5 months and episode of loose motions for 15 days 4 months back
Bladder movements : regular
Alcohol and tobacco consumption:
Occasional alcoholic since 9 years,drinks about 1 - 2 beers
Last binge of alcohol 1 beer 15 days ago
No history of tobacco consumption
Daily routine - wakes up in the morning completes his daily chores, follows personal hygiene and goes for hospital and works as a technician .his work involves lot of standing and has untimely food,sometimes even one meal per day comes back home and sleeps by 11 in the night
FAMILY HISTORY :
No significant family history
CONSENT OBTAINED
General physical examination:
The patient is conscious, coherent and cooperative, sitting comfortably on the bed.
- He is well oriented to time, place and person.
- He is moderately built and moderately nourished.
Pallor present
No signs of icterus ,koilonychia,cyanosis , lymphadenopathy,pedal edema
Pulse = 76 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay.
- Blood pressure = 110/70 mm of Hg measured in sitting position
- Respiratory rate = 20 cycles per minute
Temperature : Afebrile
O/E : multiple hyperpigmented macule noted around the stomach region and both legs with atrophy changes
hyper pigmentation around both ankle region
a single well defined ulcer noted over right great toe
no peripheral nerve thickening
Fever charting :
CVS Examination
S1 and S2 heard , No murmurs heard
Respiratory system examination
Normal Vesicular Breath sounds heard,
No added sounds
Abdominal examination
Inspection-
Shape : elliptical
Umbilicus - central and inverted
No scars,sinuses or engorged veins
Palpation:
No tenderness , No organomegaly
CNS Examination :
FINE TOUCH :
RIGHT LEFT
LOST AT S1 LOST AT S1
CRUDE TOUCH
PRESENT PRESENT
TEMP
NORMAL. NORMAL
JOINT POSITION
LOST LOST
INVESTIGATIONS :
Usg report
ECG :
CHEST X RAY
REFERRALS :
DERMATOLOGY OPINION FOR HYPER PIGMENTED MACULES :
DIAGNOSIS : INSULIN INDUCED LIPOATROPHY + TROPHIC ULCER ( RIGHT GREAT TOE )
ADVISED
1) T- BAC OINTMENT L/A BD FOR 1WEEK
2) TAB.NEUROBION FORTE 0/D FOR 2 WEEKS
3) DIABETIC FOOT CARE
ENT REFERRAL ( DIFFICULTY IN SWALLOWING TO LIQUIDS WITH REGURGITATON TO LIQUIDS SINCE 1 MONTH ): DYSPHAGIA UNDER EVALUATION
REVIEW FOR FLEXIBLE NASOPHARYNGOSCOPY AFTER DOINGB BETADINE GARGLING 1 : 10 DILUTION IN WATER FOR ABOUT SIX TO SEVEN TIMES
OPTHALMOLOGY REFERRAL (DIMINISION OF VISION IN BOTH EYES ) : MILD DIABETIC RETINOPATHY CHANGES NOTED IN BOTH EYES RE : -2.00 DSPH 6/9
LE : - 2.00 DSPH 6/9
ADVISED FOR FOLLOW UP FOR FUNDUS EXAMINATION EVERY 3 MONTHS
TREATMENT :
ON DAY 1 OF ADMISSION :
GRBS CHARTING :
1 ) INJ OPTINEURON 1 AMP IN 100 ml NS IV / OD
2 ) INJ PANTOP 40 mg IV / OD
3 )INJ.ZOFER 4 MG IV PO/SOS
3 ) INJ HAI S/C 8 AM - 2PM - 8PM
TEMP,BP,PR CHARTING 4RTH HRLY
ON DAY 2 OF ADMISSION :
GRBS CHARTING
8 PM - 299 mg/ dl 16 units HAI GIVEN AND 3 IDLY
12 AM - 44 mg / dl 25 % D GIVEN ALONG WITH RICE
2 AM - 281 mg / dl
8 AM 593 mg/dl - INJ HAI 6 U - IV / STAT
478 - 16 U ACTRAPID S/C
RX:
1 ) INJ OPTINEURON 1 AMP IN 100 ml NS IV / OD
2 ) INJ PANTOP 40 mg IV / OD
3 ) INJ HAI S/C
8 AM - 2PM - 8PM
ON DAY 3 OF ADMISSION :
GRBS CHARTING :
8 AM - 593 ( 6U IV AND 16 U S/C )
11 AM - 380
1PM - 298 (16 U S/C )
8 PM - 230 (10 U S/C )
11 PM - 253
5 AM - 358
8 AM - 485 (16 U S/C)
1 ) INJ OPTINEURON 1 AMP IN 100 ml NS IV / OD
2 ) INJ PANTOP 40 mg IV / OD
3 ) INJ HAI S/C
8 AM - 2PM - 8PM
NPH 13 U - 13 U
REGULAR. 8U 8U 8U
Advice at discharge :
1) TAB PAN 40 mg PO / OD
2) INJ HAI S/C
8 AM - 2PM - 8PM
NPH 13 U - 13 U
REGULAR 8U 8U 8U
3) HOME GRBS CHARTING
FOLLOW UP AFTER 1 WEEK .
REVORW TO ENT OPD FOR FLEXIBLE NASOPHARYNGOSCOPY
