202318809

 

 

 


Case History and Clinical Findings

PATIENT CAME WITH

C/O PEDAL EDEMA SINCE 1 WEEK

C/O TINGLING SENSATION OF LOWER LIMBS SINCE 1 WEEK C/O POLYDYPSIA SINCE 1 WEEK

 

HOPI:

PT WAS APPARENTLY ASYMPTOMATIC 1 WEEK BACK THEN HE HAD TINGLING SENSATION OF BOTH LOWER LIMBS SINCE 1 WEEK. POLYDYPSIA, POLYURIA, NOCTURIA

NO ABDOMINAL PAIN, VOMITINGS, LOOSE STOOLS

 

NO H/O CHEST PAIN, PALPITATIONS, SOB, FEVER, COLD, COUGH

 

 

PAST HISTORY:

PAST 2 YEARS BACK HE HAD ALTERED SENSORIUM AND DIAGNOSED TO HAE ?DKA, GIVEN INSULIN AND TREATED. AFTER 10 DAYS PATIENT DEVELOPED SWELLING OF LOWER LIMBS AND ULCERATION ON RIGHT TOE AND PLANTAR ASPECT OF FOOT FOR WHICH HE WAS TREATED 4 MONTHS BACK HE HAD ALTERED SENSORIUM SECONDARY TO HYPONATREMIA

?SIADH WITH HYPOKALEMIA. 2 MONTHS BACK HE AGAIN GOT ADMITTED WITH PEDAL EDEMA, ANASARCA, DECREASED URINE OUTPUT, VOMITING, LOOSE STOOLS

K/C/O DM 2 SINCE 10 YEARS K/C/O HTN SINCE 4 YEARS

NOT K/C/O TB, ASTHMA, CAD, CVD PERSONAL HISTORY ;

DIET : MIXED APPETITE : NORMAL SLEEP : NORMAL

BOWEL AND BLADDER : MICTURITION INCREASED SINCE 1 WEEK, BOWEL MOVEMENTS REGULAR

NO ADDICTIONS NO ALLERGIES

 

FAMILY HISTORY :

NO SIGNIFICANT FAMILY HISTORY

 

 

GENERAL EXAMINATION :

PATIENT IS CONSCIOUS , COHERENT , COOPERATIVE MODERATELY BUILT AND NOURISHED .

NO SIGNS OF PALLOR , ICTERUS , CYANOSIS , CLUBBING ,LYMPHADENOPATHY, EDEMA.

 

 

VITALS : TEMPERATURE: 98.4F PR - 96BPM

BP - 140/90 MMHG RR - 24 CPM

 

SPO2 - 96% ON ROOM AIR GRBS -732 MG/DL

 

SYSTEMIC EXAMINATION :

PER ABDOMEN :

INSPECTION :

ABDOMEN IS SCAPHOID UMBILICUS IS CENTRAL

ALL QUADRANTS ARE MOVING EQUALLY WITH RESPIRATION NO SINUSES , ENGORGED VEINS, VISIBLE PULSATIONS . HERNIAL ORIFICES ARE FREE.

PALPATION :

NO LOCAL RISE OF TEMPERATURE NO TENDERNESS

LIVER AND SPLEEN - NOT PALPABLE

PERCUSSION : TYMPANIC NOTE HEARD OVER THE ABDOMEN. FLUID THRILL ABSENT

SHIFTING DULLNESS ABSENT AUSCULTATION :

BOWEL SOUNDS ARE HEARD.

 

 

CARDIOVASCULAR SYSTEM :

INSPECTION:

SHAPE OF CHEST IS ELLIPTICAL. NO RAISED JVP

NO VISIBLE PULSATIONS, SCARS , SINUSES , ENGORGED VEINS. PALPATION :

APEX BEAT - FELT AT LEFT 5TH INTERCOSTAL SPACE NO THRILLS AND PARASTERNAL HEAVES AUSCULTATION :

S1 AND S2 HEARD.

 

 

RESPIRATORY SYSTEM: INSPECTION:

 

SHAPE- ELLIPTICAL B/L SYMMETRICAL

BOTH SIDES MOVING EQUALLY WITH RESPIRATION . NO SCARS, SINUSES, ENGORGED VEINS, PULSATIONS PALPATION:

TRACHEA - CENTRAL

EXPANSION OF CHEST IS SYMMETRICAL. VOCAL FREMITUS - NORMAL PERCUSSION: RESONANT BILATERALLY AUSCULTATION:

BILATERAL AIR ENTRY PRESENT

NORMAL VESICULAR BREATH SOUNDS HEARD

 

 

CENTRAL NERVOUS SYSTEM: E4V5M6

SPEECH- NORMAL

NO SIGNS OF MENINGEAL IRRITATION. CRANIAL NERVES- INTACT

SENSORY SYSTEM- NORMAL MOTOR SYSTEM:

TONE- NORMAL

POWER- BILATERALLY 5/5 REFLEXES RIGHTLEFT BICEPS ++ ++

TRICEPS. ++. ++ SUPINATOR + + KNEE. ++ . ++ ANKLE + +

BILATERAL PLANTAR FLEXOR

 

 

COURSE IN HOSPITAL:

 

A 60 YEAR OLD MALE PRESENTED WITH ABOVE MENTIONED COMPLAINTS AND ON FURTHER EVALUATION PATIENT WAS FOUND TO HAVE UNCONTROLLED SUGARS AND STARTED ON INSULIN INFUSION INITIALLY AND LATER BRIDGED TO HAI AND NPH AND SODIUM CORRECTION WAS DONE WITH 0.9%NS AND POTASSIUMJ CORRECTION WAS DONE WITH KCL INJECTION. SUGARS WERE CONTROLLED AND HYPONATREMIA AND HYPOKALEMIA ARE CORRECTED.

PATIENT RECOVERED SYMPTOMATICALLY AND DISCHARGED IN STABLE CONDITION .

 

 

Investigation HEMOGRAM:29/4/23 HB: 10.9

TLC: 10,400 CELLS/CUMM

N/L/E/M: 80/15/1/4 PLT COUNT: 2.26

ECG: NORMAL SINUS RHYTHM HBA1C-8.1

FBS(1/5/23) 129 MG/DL

HEMOGRAM:1/5/23 HB: 10.4 GM/DL

TLC: 9,900 CELLS/CUMM

N/L/E/M: 69/22/4/5 PLT COUNT: 2.32

Treatment Given(Enter only Generic Name)

1.  INJ HAI S/C TID INJ NPH S/C BD

2.  1 AMP KCL IN 500 ML NS OVER 6 HOURS

3.  IVF NS @100 ML/HR 4.TAB CINOD 10 MG PO/BD

5.  TAB MET XL 25 MG PO/OD

6.  SYP POTKLOR 10 ML IN GLASS OF WATER PO/TID

Advice at Discharge

1) PLENTY OF ORAL FLUIDS

2) INJ HAI S/C THREE TIMES A DAY 14U--14U--14U

 

8AM--2PM--8PM

INJ NPH S/C TWICE DAILY 14U--X--14U 8AM--- 8PM

3) TAB.CINOD 10MG PO/TWICE DAILY 8AM-------- 8PM

4) TAB.MET XL 25MG PO/ONCE DAILY AT 8AM

5) POTASSIUM RICH DIET


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