A case of "Persistent diabetes"
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
Date of admission : 20 December 2021
A 35 year old male patient who is a daily wage labourer has come to the OPD with the chief complaints of dizziness and vomitings since 2 days.
History of present illness :
Normal routine of the patient :
The patient gets up in the morning by 5/6 AM, has tea at 8 AM, eats rice at 10 AM and goes to the work. He used to have lunch at 1 PM and return home from work at 6 PM, he used to have dinner at 7.30 PM and sleeps by 9 PM
The patient was apparently asymptomatic 2 days back.
He started feeling dizzy while he was started around 10'o clock on 19 December. At this time he was at home only.
He then had 3 episodes of vomiting along with nausea as soon as he as he ate rice at 10 AM,the content was food which he ate, non bilious, not blood tinged, non projectile.
He then went to a local hospital where his BP was checked and was told that the BP was high and was advised to go to another hospital.
He then joined our hospital on 20 December
The patient had 3 episodes of vomiting yesterday, two were just water with no food content, yellowish in colour (patient did not eat anything) he frank milk in the evening and he vomited, which was non projectile, non bilious, non blood tinged, content was milk itself.
History of past illness :
The patient is not a known case of epilepsy, tuberculosis, asthma, hypertension
The patient is Diabetic since 10 years.
Personal history :
- The patient has no loss of appetite
- He takes mixed diet
- No sleep disturbances
- The patient consumes alcohol occasionally (90 ml)
Family history :
- There are no similar complaints in the family members
Treatment history :
- The patient is on medication for diabetes
- He is not a known case of drug allergy.
General examination :
- Patient is conscious, coherent, cooperative at the time of joining
- No pallor
- No icterus
- No cyanosis
- No clubbing of fingers and toes
- No lymphadenopathy
- Bilateral pedal edema is absent
Pulse rate - 80 bpm
Respiratory rate - 18 cycles per minute
BP - 110/90 mm Hg (150/100 at the time of admission)
GRBS : 346 mg/dl
Systemic examination :
CVS
Inspection - chest wall is bilaterally symmetrical
- No precordial bulge
- No visible pulsations, engorged veins, scars, sinuses
Palpation - JVP is normal
Auscultation - S1 and S2 heard
RESPIRATORY SYSTEM
- Position of trachea is central
- Bilateral air entry is normal vesicular breath sounds heard
- No added sounds
PER ABDOMEN
- abdomen is non tender
- bowel and bladder sounds heard
- no free fluid or mass detected
CNS :
GCS score : 14
Tone : no abnormality
Power : grade 5
Abdominal reflex is seen
Plantar reflex is seen
Tendon reflexes ( biceps jerk, triceps jerk, knee jerk, ankle jerk) - absent in both limbs
Investigations :
Diagnosis : Autonomic neuropathy secondary to diabetes
Treatment :
1. Tab Amlong 5 mg PO/OD
2. Tab. Zincovit PO/OD
3. BP monitoring 2 hourly
4. Inj. Zofer 4 mg/IV/TID
5. Inj. Pan 40 mg/IV/OD
6. T. Glucoryl M2 PO/OD
Comments
Post a Comment