1701006122 CASE PRESENTATION
LONG CASE
A 46yr old male was resident of nalgonda , farmer by occupation was brought to medicine OPD with complaints of :
Chief compliants:
Burning micturition present since 10 days
Hiccups since 3 days
Vomiting since 2 days
Giddiness, drowsiness and deviation of mouth to right since yesterday night
HOPI:
Pt was apparently asymptomatic
10yrs back pt had c/o polyuria and was diagnosed with Type 2 DM, started on Oral hypoglycemic agents 10 yr back, which pateint has been taking on and off due to financial crises.
Oral hypoglycemic agents were converted to insuline and pt underwent cataract surgery 3 yrs ago . Pt has been taking insulin three times a day befor food regularly.
h/o small injury on leg which gradually progressed to non healing ulcer extending upto below knee which turned into wet gangrene , eventually ended with below knee amputation 1yr back.
Delayed Wound healing present- wound healing took 2 months time to heal.
10 days back ,then he developed burning micturation , not associated with fever and decreased urine output.
3 days back then pateint complaints of hiccups
2 days 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 yesterday night(18/05/2022) and was brought to the hospital and GRBS was checked which was high, for which he was given NPH 10 IU and HAI 10 IU
No c/o fever/cough/cold/ abdominal pain
No c/o chest pains/palpitations/syncopal attacks.
Past history:
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
Sleep - adequate
Micturition- burning micturition present.
Bowel- regular.
DIET OF THE PATIENT:
Patient take three meals.
Morning has idly , dosa , vada any sort of tiffin.
Afternoon has rice curd vegetable dal.
Night he had porridge
No.of smalls meals...patient takes biscuits whenever he experiences an hypoglycemic attack ( feeling of giddiness , sweating )
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
General Examination:
Pt examined in well lit room and with informed consent
Pt is conscious, cooperative and coherent and we'll Oriented to time place person.
Well built and moderately nourished
Pallor present
No icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No signs of dehydration
BP: 110/80 mmHg
HR: 98 bpm
RR: 18 cpm
TEMP: 101F
SpO2: 98% on RA
GRBS: 124 mg/dL
Systemic Examination:
ABDOMEN EXAMINATION
INSPECTION:
Shape – scaphoid
Flanks – full
Umbilicus –central , inverted.
All quadrants of abdomen are moving with respiration.
No dilated engorged veins
No visible pulsations, visible peristalsis and scars.
PALPATION:
No local rise of temperature and tenderness
All inspectory findings are confirmed.
No guarding, rigidity
Deep palpation-
Liver : palpable just below costal margin ( right)
Sleep : not palpable
Kidney : not palpable
PERCUSSION:
There is no free fluid
Percussion of liver for liver span : 12cm
Percussion of spleen- dull note
AUSCULTATION:
Bowel sounds heard.
Other systems:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
CNS:
Higher function test:
Slurred speech
Cranial nerves : intact
Motor system :
1, Bulk : right. Left
Upperlimb normal. Normal
Lowerlimb. thigh -N. Normal
Below knee amputated on R side
2, Tone :
Upperlimb. Normal. Normal
Lowerlimb. Normal. Normal
3, Power :
Neck:. Normal
Trunk:. Normal
Upper limb 5 5
Lower limb 5 5
4, Reflexes
Right Left
Biceps 2+. 2+
Triceps 2+ 2+
Supinator. 2+ 2+
Knee 1+ 1+
Ankle . 1+
Planter reflex Amputated flexion
Sensory system : reduced proprioception,vibration,pain and temperature sensation at distal ends of lowerlimb.
Meaningeal signs : negative
Investigations:
19/05/2022: ( on admission)
X ray KUB:
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CT scan
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USG abdomen pelvis
Urine examination:
Complete blood picture:
Liver function test:
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A 22 year old male,painter by occupation presented with complaint of abdominal pain since 4 days.
History of present illness:
Patient was apparently asymptomatic 4 months back then he developed epigastric pain and vomiting on presenting to a hospital diagnosed as Acute Pancreatitis. He was treated at the hospital and was discharged with the advice to stop drinking alcohol.
4 days back , he developed pain over upper abdomen which is of dragging type, radiating to back aggravated after meals and on lying down(prone>supine)position
Patient denies history of fever, nausea, and diarrhoea.
Patient initially desired to show up for alcohol de-addiction,but was eventually referred to medical opd being syptomatic for pain.
Past History:
Not a known case of Diabetes mellitus, Hypertension. Epilepsy, Cardiovascular diseases. Asthma and tuberculosis
Family History:
No similar complaints in family.
Not significant
Personal history:
Takes mixed diet,
Appetite:Reduced (Early satiety)
Sleep is Adequate.
Bowel and bladder habits are regular
Addictions: Started drinking alcohol 3 years back with friends and later the amount of alcohol incresed to 12 units.
1 Unit=10ml
alcohol daily since 3 years.
Reduced intake to 5 units since 3 months. Last intake was 5 days back of about 8 units of alcohol.
Smokes 7-8 beedies per day
General physical examination: Patient is conscious, coherent,cooperative and well oriented to time, place and person.He is of thin built.
There is no pallor.
No signs of icterus, cyanosis, clubbing lymphadenopathy
edema - present
Vitals:
Patient is afebrile
Pulse rate: 92 bpm
Blood pressure: 110/80 mm of Hg
Respirtaory rate: 14 cpm
Systemic Examination:
ABDOMEN EXAMINATION:
INSPECTION:
Shape – Flat
Umbilicus –central in position
All quadrants of abdomen are moving equally with respiration.
No dilated veins, hernial orifices, sinuses
No visible pulsations.
Patient had a swelling left costal border slightly medial to midline .
Not moving with respiration.
PALPATION:
Slight local rise of temperature on left side and no tenderness
All inspectory findings are confirmed.
No guarding, rigidity
Deep palpation- no organomegaly.
PERCUSSION:
There is no fluid thrill , shifting dullness.
Percussion over abdomen- tympanic note heard.
AUSCULTATION:
Bowel sounds are heard.
Investigations:
Serum Lipase: 112 IU/L (13-60)
Serum Amylase: 255IU/L (25-140)
Hemogram:
Hemoglobin: 11.8 mg/dl
Total leucocytes: 14,300 cells/cumm
Lymphocytes: 16(18-20)
Provisional diagnosis: Pseudocyst of pancreas
Treatment:
Nill Per Oral
Intravenous fluids Ringer lactate and normal saline 10ml per hour
Inj. TRAMADOL 100 mg in 100ml normal saline IV BD
INJ. ZOFER 4mg IV BD
INJ. PAN 40 MG IV BD
INJ. OPTINEURIN 1amp in 100 ml nd IV OD
Psychiatric medication:
TAB. LORAZEPAM 2mg BD
TAB. BENZOTHIAMINE 100mg OD
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