1701006095 CASE PRESENTATION
LONG CASE
A 46 year old male came to hospital with the chief complaints of
-burning micturition since 10 days
-vomiting since 2 days (3-4 episodes)
-giddiness and deviation of mouth since 1 day
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10years back, he complained of polyuria for which he was diagnosed with Type 2 diabetes mellitus,he was started on OHAs, 3years back OHAs were converted to insulin.
20days back he developed vomiting containing food particles, non bilious,non foul smelling(3-4 episodes),later he complained of giddiness and deviation of mouth for which he was brought to our hospital and his GRBS was recorded high value for which he was given NPH 10U and HAI 10U.
No history of fever/cough/cold.
No significant history of UTI's.
Past history:
10years back- patient complained of polyuria for which he was diagnosed with Type 2 Diabetes Mellitus he was started on oral hypoglycemic agents(OHA) 10years back
3years back- OHAs were converted into Insulin
3years back- he underwent cataract surgery
1year back- he had injury to his right leg, which gradually progressed to non healing ulcer extending upto below knee and ended with undergoing below knee amputation due to developement of wet gangrene.
Delayed wound healing was present- it took 2months to heal
Not a k/c/o Hypertension, Epilepsy,Tuberculosis, Thyroid
Not on any medication
No history of blood transfusion
PERSONAL HISTORY:
Diet - Mixed
Appetite- normal
Sleep- Adequate
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.
FAMILY HISTORY:
Not significant
VITALS @ Admission:
BP: 110/80 mmHg
HR: 98 bpm
RR: 18 cpm
Temperature: 99°F
SpO2: 98% on RA
GRBS: 124 mg/dL
GENERAL EXAMINATION:
Pallor: present
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: Absent
No dehydration
CVS: S1 and S2 heard, No murmurs
RS: BAE+, Normal vesicular breath sounds heard
P/A: Soft, Non tender
CNS:
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
INVESTIGATIONS:
On admission (19.5.22)
A 80 years old male resident of Marrigudem, agriculture labourer by occupation came to OPD with the chief complaints of
-Fever since 3 days
-An episode of vomiting 2 days back
-Decreased urine output associated with burning micturition since - since 2 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 3 days back.
He has fever which was insidious in onset,gradually progressive, with no diurnal variations and relieved on medication. It was associated with chills, rigors and generalised body pains. It is not associated with cough, cold, shortness of breath and night sweats.
An episode of vomiting 2 days back which is of only food which is non bilious and not foul smelling and colour is same as the food colour.
There is burning micturition which is experienced at the start of the urinary flow and relieved after the urination and decreased urine output since 2 days which is not associated with any hematuria.
PAST HISTORY:
He was with similar complaints in the past 10years ago, then he consulted a local doctor and relieved on medication (may be antibiotics). And there is continuation of such episodes then refered to higher hospital and diagnosed with renal problem (AKI) which was treated with dialysis once and given some diuretics as he is suffering from oliguria.
He has a recurrent episodes of fever with burning micturition later also.
He is known case of hypertension since 24years.
Not a known case of Diabetes, Tuberculosis, Asthma and Epilepsy.
SURGICAL HISTORY:
He had underwent a nephrectomy surgery 27 years ago. Donated a kidney to his brother.
PERSONAL HISTORY:
Appetite - normal
Diet- mixed
Sleep - adequate
Bowel - regular
Bladder - oliguria since 2 days, associated with burning micturition, feeling of incomplete voiding.
Habits/Addiction: 3 beedi/ day from 27yrs of age and Alcohol- occasionally.
He stopped both alcohol and smoking after the nephrectomy surgery.
GENERAL EXAMINATION:
Patient is conscious, coherent, co operative and well oriented to time, place, and person moderately build and nourished.
Pallor: Present
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: Absent
Pedal edema: Present
It was gradually progressive, pitting type, bilateral, Below knees.Grade 2
No local rise of temperature and tenderness
Not relived on rest.
Pallor
Pedal edema
VITALS:
Febrile 99.2F
BP : 150/90 mmHg (on medication)
Pulse rate: 76 bpm
SYSTEMIC EXAMINATION:
CVS: No visible pulsations, scars, engorged veins. No rise in jvp. Apex beat is felt at 5 ics medial to mid clavicular line. S1S2 heard . No murmurs.
RS: Shape of chest is elliptical, b/l symmetrical. BAE+, Normal vesicular breath sounds heard.
Per abdomen:
No visible pulsations and scars swellings.
Soft, non tender, no organomegaly.
Umbilicus is inverted.
No abdominal distention
CNS:
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.
INVESTIGATIONS:
TREATMENT:
Inj. Piptaz -2.25gm/tid
Tab. Lasix - 40ug/po/ bd
Tab. Zofer - 4mg/po/ sos
Tab. Dolo - 650/ po/ sos
Tab. Pan 40mg /po/ od
Nebi. Duolin and Budecort 6hrly
Syr. Mucaine gel 15ml/po/ bd before meal 15min
Syrup. Cremaffin 15ml/po/ sos.
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