1801006039 CASE PRESENTATION

 LONG CASE 

A 43 year old male from Suryapet, Daily wage worker by occupation came to hospital with

C/o Wound over the posterior aspect of right foot with foul smelling discharge since 6 months

History of Presenting Illness

Patient was apparently asymptomatic 6 months ago then he developed infection in heel crack insidiously which progressed gradually to the current wound size. Wound was taken care by regular dressing at a local hospital 

Patient developed  Right lower limb edema 2 weeks back which was insidious in onset and gradually progressed from ankle to knee

Patient developed fever 10 days back and subsided 3 days back which was associated with chills, body pains, cough and cold and 2 episodes of Vomiting for 3 days. Symptoms improved on taking medication.

1 day back foul smelling purulent discharge was found to be oozing out of the wound so patient came to hospital to get it treated. 

H/o polyuria, nocturia

No h/o polydipsia, polyphagia

No h/o burning micturition

No apparent h/o trauma to the right foot

Past History 

K/c/o Type 2 Diabetes Mellitus since 10 years and is on Metformin medication (1000 mg  morning and 500 mg night)

Not a k/c/o Hypertension, TB, Epilepsy, CVA, CAD, Asthma

H/o hemorrhoids surgery 10 years back

Personal history 

Patient is a daily wage worker lifting weights everyday as a part of his work

Appetite is decreased since 1 week

Diet is Mixed

Sleep is adequate 

Bowel movements are regular 

Polyuria and Nocturia present

Chronic alcoholic since 20 years 

Has been chewing Gutka for the past 20 years

General Physical Examination 

Patient is Conscious  and Co operative

Well oriented to time, place and person 

No Pallor, Icterus,  Clubbing,  Cyanosis,  Koilonychia, Generalised Lympadenopathy

Patient has Right lower limb below knee pitting type of edema. 

Local rise of temperature over the edematous limb

Vitals:

Temp: afebrile

PR: 96 bpm

RR: 20 /min

BP: 140/90 mm hg

GRBS- 550 mg/dl

Systemic Examination 

CVS: S1 S2 heard

Apex beat palpable in left 5th ICS

Respiratory system:

Non Vesicular Breath Sounds heard

Abdominal Examination 

Abdomen is scaphoid in shape and Umbilicus is inverted. Equal symmetrical movements in all quadrants with respiration and no visible peristalsis and pulsations over Abdomen

No Organomegaly, No tenderness

Bowel sounds heard

CNS:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES :Normal

SENSORY EXAMINATION

Spinothalamic sensation (Crude touch, Pain, Temperature) intact

Dorsal column sensation of fine touch and Proprioception intact

Vibration -  Decreased sensation in lower limbs

Cortical sensation ( Two point discrimination,  tactile localisation) intact.

MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee reflexes.

Ankle reflex on right side could not be elicited due to presence of ulcer

CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

Investigations 

On the day of admission  (15/03/2023)

RBS  is 419 mg/dL

Blood Urea is 49 mg/dL

CUE shows Acidic reaction with ++ Albumin and ++++ Sugars

Negative Serology findings for HBsAg, HIV 1/2 and Anti HCV antibodies 

Hemogram

Hb  10.7 gm/dL

Total count  17,300 cells/cumm

Neutrophils 8.8 %

Lymphocytes  07 %

PCV   31.1 vol%

RBC count  3.54 millions/cumm

Serum Creatinine   2 mg/dL

Serum electrolytes 

Sodium 128 mEq/L

Potassium 5.2 mEq/L

Urine positive for Ketone bodies 

ABG

pH  7.34

pCO2  22.7

pO2  35.9

On 16/03/2023

Sodium 132 mEq/L

Potassium 4.4 mEq/L

ABG

pH 7.39

pCO2 25.3

pO2 88

HbA1C 6.8

Chest X ray 

Electrocardiogram 

Diagnosis 

Diabetic Ketoacidosis withChronic non healing ulcer

 

Treatment plan

NBM

Inj. HAI 6U/IV/STAT

IV Fluids- NS

      1st hour- 1lit

      2nd hour-500ml

      3rd hour- 500ml

Then 250ml/hr till 24 hours

Inj. HAI infusion 1ml (40units) in 39ml NS at 6ml/hr 

On 16/3/23:

IV Fluid- FLUSODEX at 100ml/hr

Human Actrapid Insulin infusion at 3ml/hr

Inj. METROGYL 500mg IV/TID

Inj. PAN 40 mg PO/OD

Inj. THIAMINE 200mg in 100 ml NS BD

Strict output monitoring

GRBS monitoring hourly

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SHORT CASE

A 42 year old male from Nalgonda district, a Government employee by occupation came to our OPD with 

C/o Abdominal distention since 7 days

       Bilateral Pedal Edema since 3 days

History of Presenting illness

Patient was apparently asymptomatic 10 days ago then he developed Abdominal discomfort which increased on taking food 

Patient developed gradual Abdominal Distention 1 week back which was associated with Shortness of breath even on sitting and while talking

Patient has complaints of burning sensation of legs and hands for the past one week for which he visited a Neurosurgeon at Nalgonda and was prescribed Gabapentin on the provisonal duagnosis of Sensory Axonal Neuropathy. Patient achieves short term relief with the medication.

3 days back patient noticed bilateral mild pedal edema on his way to office which increased by the end of the day and still persists.

Past History

Patient had H/o Jaundice 2 years back which was diagnosed on admission for Dengue hemorrhagic fever and was unconscious for about 3 days.

Not a k/c/o Diabetes mellitus, Hypertension, TB, Epilepsy, Asthma, CAD.

Personal history

Diet is mixed

Appetite is decreased 

Sleep - Inadequate for the past 10 days but improved after taking Gabapentin for burning sensation of legs and hands

Bladder movements - Decreased urinary flow, dark coloured, foul smelling urine with burning sensation post micturition for the past 10 days.

Bowel movements every 2 days

Addictions - Chronic Alcoholic for the past 6 years and consumes more than 180ml whiskey every day.

No habit of Cigarette smoking.

History of weight loss in the past 2 years of about 20 kgs (70kgs to 50 kgs)

Family history- No similar complaints in the family

Drug History - On Gabapentin for the past 5 days

Surgical history - Underwent Appendicectomy surgery 17 years back

Daily Routine 

Patient usually wakes up at 5am everyday and goes to work around 9am skips breakfast and has lunch around 4pm. He suffers with hunger pain in the epigastrium during early afternoon which radiates to the back and chest. Drinks alcohol at night and skips meals most of the times and sleeps around 11pm.

General Physical Examination 

Patient was Conscious, Coherent and Cooperative.

Well oriented to time, place and person. 

Undernourished and under built.

Pallor present 

No Icterus, Cyanosis, Clubbing, Koilonychia, Generalised Lymphadenopathy

Bilateral Pedal edema present of Grade 2.

Vitals

Temperature - Afebrile 

Pulse - 90 bpm

Respiratory rate - 22 cpm

Blood pressure - 120/80 mmHg

Systemic examination 

CVS - S1,S2 heard

RS - BAE +

CNS - No focal neurological deficits

Abdomen

On Inspection 

Abdomen is distended

Flanks are full

Umbilicus is central and inverted 

Skin is stretched with Dilated veins on sides of the Abdomen 

Appendicectomy scar present 

On Palpation

Soft

Mild tenderness over Right Hypochondriac region 

Liver not palpable 

Spleen not palpable

On Percussion 

Shifting dullness present 

Liver span was difficult to percuss due to distended abdomen.

Provisional Diagnosis 

Ascites secondary to Chronic Liver Disease

Investigations 

Hemogram

RBS, HbA1c

CUE

LFT

serum Creatinine 

Urea

Serum electrolytes

ECG

Chest X Ray PA view 

USG Abdomen 

PT, INR 

APTT

BT, CT

Ascitic tap 

Management 

Fluid restriction to <1 L/day

Salt restriction to <2 gm/day

Inj. LASIX 40mg IV BD

Syrup Lactulose 30ml PO

BP/ PULSE/ RR/ TEMP Charting 4th hourly.