A 35 YR OLD MALE WAS BROUGHT TO THE CASUALITY WITH C/O ALTERED SENSORIUM AND GENERALISED WEAKNESS

 Case History and Clinical Findings

A 35 YR OLD MALE WHO WAS ATRUCK DRIVER BY OCCUPATION WAS BROUGHT TO THE CASUALITY WITH C/O ALTERED SENSORIUM AND

GENERALISED WEAKNESS SINCE 1WEEK

HOPI-

PT. WAS APPARENTLY ASYMPTOMATIC 10YRS AGO THEN HE DEVELOPED COUGH AND GENERALISED WEAKNESS FOR WHICH HE WENT TO HOSPITAL AND DIAGNOSED WITH DM AND WAS PRESCRIBED OHAS SINCE THEN HE STARTED USING OHAS BUT WAS ON IRREGULAR MEDICATION AND HAD POOR CONTROL OF SUGARS .THEN WAS ON INSULIN SINCE 7YS,STOPPED USING INSULIN FROM 15DAYS

2 YRS BACK HE DEVELOPED BOTH LL SWELLING WHICH GRADUALLY PROGRESSED TO ANASARCA SINCE THEN HE HAD FREQUENT ATTACKS OF HYPOGLYCEMIA AND DECREASED URINE OUTPUT

3 MONTHS BACK.PT.DEVELOPED FEVER WITH ULCER OVER RIGHT GREAT TOE. LOWER LIMB AND FACIAL PUFFINESS AGGRAVATED ,BROUGHT TO OUR HOSPITAL AND WAS ADMITTED AND DISCHARGED

SINCE 7DAYS,PT. HAD GENERALISED WEAKNESS , ALTERED BEHAVIOUR ,INCREASED SLEEPINESS DURING DAY TIME,ALTERED SLEEP CYCLE SINCE 1WEEK, AND WAS BROUGHT TO OUR HOSPITAL

PAST HISTORY-

K/C/O DM SINCE 10YRS AND ON INSULIN

DIAGNOSED WITH DM 10YRS BACK AND WAS PRESCRIBED OHAS SINCE THEN HE STARTED USING OHAS BUT WAS ON IRREGULAR MEDICATION AND HAD POOR CONTROL OF SUGARS .THEN WAS ON INSULIN SINCE 7YS.STOPPED USING FROM 15DAYS

K/C/O HTN SINCE 2YRS AND ON REGULAR MEDICATION

NOT A K/C/O TB/CAD/EPILEPSY/ASTHMA

PERSONAL HISTORY-

MIXED DIET

APPETITE DECREASED

BOWEL AND BLADDER HABITS -REGULAR

ADDICTIONS-CHRONIC ALCOHOLIC AND TAKES DAILY 90-180ML FOR ABOUT 10YRS AND STOPPED 2 YRS BACK

NO ALLERGIES

GENERAL EXAMINATION: AT PRESENTATION

PT. IS DROWSY/COHERENT/COOPERATIVE

PALLOR PRESENT

B/L PEDAL EDEMA PRESENT

NO ICTERUS, CYNOSIS, CLUBBING, LYMPHEDENOPATHY

TEMP- 98F

PR-98BPM

BP- 150/100MMHGSPO2-98% @ RAGRBS-HIGH

CVS- S1S2+,NO MURMURSRS-

R/s:- BAE+,NVBS HEARD

P/A- SOFT,NON TENDER,BOWEL SOUNDS+

CNS- ORIENTED TO TIME,PLACE AND PERSON

LEVEL OF CONSCIOUSNESS- DROWSY/AROUSABLE

SPEECH-SLURRED

NO SIGNS OF MENINGEAL IRRITATION

CRANIAL NERVES INTACT

NO SENSORY ABNORMALITY DETECTED

GCS 15/15

B/L PUPILS NORMAL IN SIZE AND REACTIVE TO LIGHT

AT THE TIME OF DISCHARGE:

PT. IS CONSCIOUS/COHERENT/COOPERATIVE

COURSE IN THE HOSPITAL:-

35 YEAR OLD MALE ADMITTED IN THE HOSPITAL WITH ABOVE MENTIONED COMPLAINTSNECESSARY INVESTIGATIONS WERE DONE ,

CONSERVATIVELY MANAGED

3 UNITS PRBC TRANSFUSIONS DONE ON[18/2/23,19/2/23,21/2/23]SYMPTOMS SUBSIDEDPATIENT HEMODYNAMICALLY STABLE AND PLANNED FOR DISCHARGE

GENERAL SURGERY OPINION TAKEN I/V/O DIABETIC FOOT

ADVICED ARTERIOVENOUS DOPPLER OF RT. LOWER LIMB,C/S OF DIABETIC FOOT SWAB

ARTERIOVENOUS DOPPLER OF RIGHT LOWER LIMB:

1.PROXIMAL PTA AND DPA SHOW BIPHASIC WAVIFORM,REST OF ARTERIES SHOW TRIPHASIC WAVIFORM

2.ALL EXAMINED VEINS SHOW NORMAL COLOUR UPTAKE WAVIFORM,RESPIRATORY PHASICITY

DIABETIC FOOT ULCER SWAB C/S:

FEW EPITHELIAL CELLS,FEW DISINTEGRATED PUS CELLS,MODERATE NUMBER OF GRAM NEGATIVE BACILLI,PLENTY OF GRAM POSITIVE BUDDING YEAST CELLS SEEN.

KLEBSIELLA PNEUMONIA ISOLATED

SENSITIVE TO GENTAMICIN,COTRIMOXAZOLE,AMIKACIN,MEROPENEM

RESISTANT TO AMOYCLAV,CEFUROXIME,CEFTAZIDIME,CEFEPIME

OPHTHALMOLOGY OPINION TAKEN I/V/O ANY DM AND HTN RETINOPATHIC CHANGES

ADVICE : FUNDOSCOPY DONE -NO RAISED ICT ,NO CHANGES OF HTN AND DIABETIC RETINOPATHY CHANGES

NEPHROLOGY OPONION TAKEN I/V/O SR.UREA-108MG/DL AND S.CREA-3.1MG/DL

ADVICED TAB.TELMA 40MG PO/OD

INJ.LASIX 20MG IV/BD

INJ.MEROPENEM 1GM IV/TID

INJ.INSILIN ACCORDINGLY EVERY 4TH HRLY

ENDOCRINOLOGY OPINION TAKEN I/V/O

Provisional Diagnosis:-

UNCONTROLLED SUGAR SECONDARY TO SEPSIS

SEPTIC ENCEPHALOPATHY (RESOLVED)

WET GANGRENE OF RIGHT GREAT TOE(RAYS AMPUTATION DONE)

ACUTE RENAL FAILURE ON CHRONIC KIDNEY DISEASE(DIABETIC NEPHROPATHY SINCE 2 YRS)

ANEMIA OF SHRONIC KIDNEY DISEASE

THROMBOCYTOPENIA (RESOLVED)

H/O DIABETES MELLITUS SINCE 10YRS

H/O HYPERTENSION SINCE 2YRS

Investigation:-

PT-15SECS

APTT-31SECS

INR-1.11

ECG-NORMAL SINUS PATTERN

2D ECHO:-

MILD TO MODERATE TR+ WITH PAH, MILD MR+,TRIVIAL AR+

NO RWMA,NO AS/MS,CONCENTRIC LVH+

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DISFUNCTION

EF-56%

BGT-A POSITIVE

HEMOGRAM;

HB. , TLC PLC

GM/DL CELLS/CUMM

17/02/23 6.0 21,600 95,000

19/02/23 5.8 15,400 42,000

20/02/23 6.5 13,500 46,000

21/02/23 6.3 11,000 33,000

22/02/23 8.2 14,000 96,000

23/2/23 7.1 9000 1,OO,200

USG ABDOMEN:

MODERATE ASCITIS

LEFT MILD PLEURAL EFFUSION

C/S OF URINE:

NO GROWTH SEEN

C/S OF BLOOD:

SKIN COMMENSALS GROWN

24 HRS URINARY PROTEIN -654MG/DAY

24HRS URINARY CREATININE -2.89G/DAY

Treatment Given:

NBM TILL FURTHER ORDERSIVF -NS@ 50ML /HRINJ.NAHCO3NBM TILL FURTHER ORDERSIVF -NS@ 50ML IV STATINJ.NAHCO3 50MEQ/L F/B 50MEQ/LINJ. HAI 6U IV STAT F/B ACCODING TO GRBS

INJ.PIPTAZ 4.5G IV STAT F/B 2.25GIV TID

INJ.CLINDAMYCIN 600MG IV / TIDSTRICT I/O CHARTINGGRBS MONITORING HOURlY

21/2/23:

DATE TIME GRBS INSULIN GIVEN

21/02/23 8AM 101 4U HAI+4U NPH

2PM 127 6U HAI

8PM 176 8U HAI

22/02/23 8AM 201 6U HAI+4 U NPH

2PM 100 6U HAI

8PM 79 4U HAI

23/02/23 8AM 198 6U HAI+4U NPH

12PM 100 6U HAI

8PM 92 4U HAI

Advice at Discharge:-

STRICT DIABETIC DIET

INJ.MIXTARD /SC

12U -----0-----8U

INJ.ERYTHROPOITIN 400UNITS/SC/TWICE WEEKLY

TAB.LASIX 40MG PO/BD

TAB.NICARDIA 10MG PO/TID

TAB.BACTRAM DS PO/BD X 5DAYS

TAB.CHYMEROL FORTE PO/TID

TAB.NODOSIS 500MG PO/OD

TAB.SERAX FORTE 20MG PO/TID

FLUID RESTRICTION <1.5 LITS/DAY

SALT RESTRICTION <2GM/DAY

RIGHT LOWE LIMB ELEVATION

REGULAR DRESSINGS

ACTIVE AMBULATION