1601006158 case presentation
LONG CASE
46y/M came with c/o drowsiness (altered sensorium) since 19/05/2022 morning,
c/o vomiting (3-4 episodes) since 3weeks
Hiccups since 3weeks
Burning micturition present since 1month
HOPI:
Pt was apparently asymptomatic
3weeks back, then pt developed c/o vomiting ,had 4-5 episodes, containing food particles,non bilious.
Pt c/o deviation of mouth and giddiness since (18/05/2022)
(18/05/2022)- GRBS recorded high value for which he was given NPH 10 IU and HAI 10 IU
No c/o fever/cough/cold
No significant h/o previous UTIs
No c/o chest pains/palpitations/syncopal attacks
Past History:
10yrs back pt had c/o polyuria and was diagnosed with Type 2 DM, started on OHA 10 yr back,
h/o small injury on leg which gradually progressed to non healing ulcer extending upto below knee eventually ended with below knee amputation 1yr back i/v/o development of wet gangrene
OHAs been converted to Insulin since 2 yrs
Delayed Wound healing present- wound healing took 2 months time to heal
3 years back pt underwent Cataract surgery
K/c/o DM type 2 on medication-insulin
Not a k/c/o HTN/Epilepsy/TB/BA/Thyroid disorder/CAD/CVD
Not on any other medication
No h/o blood transfusion
Personal History:
Married
Appetite-Normal
Diet-Vegetarian
Bowel and Bladder - Regular
Micturition- burning micturition present
Habits/Addiction:
Alcohol-
Not consuming alcohol since 1 yr.
Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.
Also 1 month on & off consumption pattern previously present
Family history:
Not significant
Vitals @ Admission:
BP: 110/80 mmHg
HR: 98 bpm
RR: 18 cpm
TEMP: 101F
SpO2: 98% on RA
GRBS: 124 mg/dL
General Examination:
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal
Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS:
Pt is having altered sensorium
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
Normal
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs
No meningeal signs
Clinical Images:
Provisional Diagnosis:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis secondary to Sepsis
H/o Type 2 DM since 10 yrs
Investigations Reports:
XRay- KUB
Treatment:
INJ. MEROPENEM 500mg IV BD
INJ. ZOFER 4mg IV TID
INJ. PAN 40mg IV OD
IV Fluids- NS,RL @ 100 mL/hr
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
RT feeds- 2nd hrly 100 mL water
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SHORT CASE
20 year old female student by occupation came with the chief complaints of abdominal pain since a weak
History of 3 episodes of vomiting present( bilious in content non projectile).
Chief complaints of pain abdomen in epigastric region insidious in onset gradually progressive in nature associated with vomitings.
Patient was apparently asymtomatic 3 years back, met with an RTA and was admitted in hospital and diagnosed with Diabetes type 1 and was on Insulin mixtard subcutaneous ( 12u----x-----12u ).
Patient was alright till 8 months back then she had epigastric pain radiating to back insidious in onset and was diagnosed with acute pancreatitis and was on conservative management till then.
After 10 days, she developed hyperpigmented spots and patches on her lower back and lower limbs for which she consulted the doctor several times but they did not resolve.
Non alcoholic , Non smoker.
GENERAL EXAMINATION
NO Pallor , Icterus , Cyanosis , Clubbing ,lymphadenopathy.
Vitals
Temp - afebrile
BP - 120/100 mm hg
PR - 120 bpm.
RR - 19 cpm
spo2 100 @RA
GRBS - 259 mg/dl @ 3 Pm
CVS - S1, S2 heard
RS : bae present
P/A : soft , tender , Guarding Present
CNS : NA
INVESTIGATION
On 24/03/2022
Serum Lipase - 135
Serum Amylase - 261
On 28/03/2022
Serum Lipase - 36
Serum Amylase - 69
RBS - 292 mg/dl
Urine Protein/Creatinine Ratio :
Spot urine protein : 45.7 mg/dl
Spot urine creatinine : 83mg/dl
Ratio : 0.55
Sickling Test on 27/03/22 - Negative
Rapid Dengue 27/02/22 - Negative
Serum Lipid Profile on 24/03/2022
Total Cholesterol - 261
Triglycerides - #932
HDL Cholesterol - #81
LDL Cholesterol - # 150
HAEMOGRAM 23/03/2022
Haemoglobin - 13 gm/dl
Total Count - 13,200
RBC - 5.46
Platelet Count - 3.36 lakh
HAEMOGRAM 27/03/2022
Haemoglobin - 11.7 gm/dl
Total Count - 8,300
RBC - 4.87
Platelet Count - 3.68 lakh
RFT
S Urea - 29
S Creatinine - 0.7
Uric acid - 8.8
S Calcium - 10.2
Na - 137
K - 4.5
Cl - 98
LFT
Total Bilirubin - 1.52
Direct Bilirubin - 0.62
Ast - 17
Alt - 9
Alk P - 181
Total Protein - 6.8
Albumin - 3.37
A/G - 0.98
CRP -
HbA1c - 6.9 %
Serology -
ECG
2D Echo
Chest Xray PA View
USG Abdomen
CECT Abdomen
DIAGNOSIS
Acute Pancreatitis with DKA with Type 1 Diabetes Mellitus ( since 3 year)
TREATMENT
1. Nbm till further orders.
2. IVF- NS & RL @ 150ml/hr.
3. Inj HAI ( 39ml Normal Saline + 40 IU HAI ) @ 4 ml / hr according to Algorithm
4. Inj. Pantop 40mg/IV/OD.
5. Inj. Zofer 4mg/IV/OD.
6. Inj. Tramadol 1amp in 100 ml/NS/IV/BD.
7. Inj. THIAMINE 2amp in 1 NS/IV/TID.
8. Monitor vitals.
9. Measure abdominal girth
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