CASE HISTORY 3
March 16, 2022
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CHIEF COMPAINT:
A 65Y/M cloth weaver by occupation came to OPD this morning (16/03/22) with C/O giddiness since 2 days
HOPI:
▪️Pateint was apparently asymptomatic 15 years back , on regular checkup he was came to be diagnosed with DM-II and HTN.
▪️On oral hypoglycaemic agents for 10 years
▪️4 years back due to trauma ,due to non-healing ulcer irt Lt great toe has been dis articulated , h/o above ankle amputation was done.
▪️ Due to uncontrolled sugar level since then he is on Inj.human mixtard insulin.
▪️c/o Vomitings since 15 days
No c/o Abd pain, Abd distention
No c/o pedal edema
Facial puffiness +
No c/o chest pain, palpitation
PAST HISTORY:
K/C/O DM-II since 15 years
K/C/O HTM since 15 years
TREATMENT HISTORY:
Diabetes - yes
Hypertension - yes
Blood transfusion - yes
Surgeries - Above Ankle amputation four years back
PERSONAL HISTORY:
Diet - mixed
Appetite - normal
Sleep - adequate
Micturation - abnormal
No habit of smoking and drinking
FAMILY HISTORY:
No similar history in the family
GENERAL EXAMINATION:
-Patient is conscious,coherent and cooperative at the time of joining
-pallor is present
-No icterus
-No lymphadenopathy
-No cyanosis
-No clubbing of fingers
-No edema of feet
-No malnutrition
-No dehydration
▪️VITALS:
Temperature - 98.6 F
Pulse rate - 96 bpm
Respiration rate - 20 cpm
BP - 120/70 mmhg
Spo - 98%
GRBS- 145 mg/dl
SYSTEMIC EXAMINATION:
▪️CVS
-no thrills
-no cardiac murmur
-S1&S2 sounds are heard
▪️RESPIRATORY SYSTEM
-BAE present
▪️CNS
-Patient is conscious
-Speech is present
-Normal reflexes
INVESTIGATIONS:
16/03/22
▪️BGT: B positive
▪️FBS: 165
▪️PLBS : 169
▪️Hemogram:
Hb-6.3
TLC-TLC-9,000
Pl-10
MCV-16.9
MHC-79.7
PCV-2.12
▪️LFT:
TB- 1.05
DB-0.42
AST-30
ALT-12
ALP-244
TP-5.9
ALB-3.0
▪️RFT:
Urea: 90
Creatinine:4.7
▪️Electrolytes:
Na+:111
K+:4.5
Cl-:70
▪️urine-protien/creatine ratio : 3.51,
3.9 (9:50pm)
▪️CUE:
Reaction: acidic
Albumin:+++
17/03/22
Urea : 89
Sr.creatine: 4.8
Na+ :115
K+ :4.3
Cl- : 81
USG abdomen:
ECG:
PROVISIONAL DIAGNOSIS:
Hypoglycaemic 2⁰ to insulin
Chronic renal failure( Diabetic nephropathy)
TREATMENT:
1. GRBS charting 2nd hourly
2. inj zofer 4mg/IV/TID
3. inj ∙PAN 40mg IV/BD
4.IVF UO + 30ml/hr
15. Tab. Lasin 40mg PO/ BD
6. Tab. shelcal PO / OD
7. inj erythropoetin 4000 IU/SC
Weekly once
8. Inj. 3% Nacl 15ml/hr
