50 year old Man with uncontrolled DM 2
Medical case disscussion
July 28,2022
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Name : Mounika 8th sem
Roll no : 46
I have been given this case to solve an attempt to understand the topic of "patient clinical analysis of data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan
CASE DISCUSSION
A 50 year old man who's a resident of nakrekal,labourer by occupation came to the opd to get admitted under de-addiction
HOPI :
Patient was appareantly asymptomatic 4 years back ,then he developed
• Burning type of pain in the right and left hypochondrium,3 to 4 episodes for which he went to a local hospital and got medications(He's a chronic alcoholic since 30 years), and the symptoms subsided,his last episode was the day after he got admitted here and was given pantop iv and the symptoms subsided.
• H/o weight loss approximately 20 kgs since 15 months
• 1 year back he was found to have high Sugars at a government camp at his place used OHA's for 4 months
• Then he developed complaints of Generalized weakness, polydypsia, poly urea for which he visited a private hospital at Nakrekal found to high sugars (Uncontrolled DM 2 ) He was on insulin(10 U morning,5U in the night) since then (took Insulin Irregularly) .
• Complaints of Diminution of vision since 8 months and double vision in the mornings since 7 months
• H/o light trauma 3 month back then he developed bubble like lesions along the right 3-4ICS , associated with pain and itching for which he went to a local hospital and got some medications and pain and itching decreased in intensity ,later Complaints of shooting type of pain along the dermatome (on right side of 3-4 ICS,intermittent in nature,occuring one or twice for about 5 to 10 minutes once in 3days since 29/7/22 ,associated with itching and tingling sensation
• H/o Trauma (with mild skin abrations over the ankles and bony prominences ) 15 days back,then he developed itching over the wounds
Came to the opd and got admitted for de-addiction and was sent to GM for uncontrolled DM 2(550mg/dl)
• Complains of body pains since 3 days for which he was given tramadol
• Vomitings on 1/8/22 morning
2 episodes ,projectile type with food particles as content( early in the morning& after consuming milk) for which he's given medication and the symptoms subsided
• Burning type of pain in the right and left hypochondrium and epigastric regions since 2/8/22 on and off for 1to 2 hours in a day
• Fever since 3/8/22 which is low grade, intermittent in nature, not associated with chills and rigor and got relived on medication
PAST HISTORY :
K/c/o DM 2 since 1 year
Not a K/c/o Hypertension ,asthma ,CAD, epilepsy, hypothyroidism
PRESENT HISTORY
Daily routine :
He was a labourer by occupation.
Wakes up at 6 AM
Does household work
Breakfast at 9 AM
Goes to work
Lunch at 2 PM
Returns home 6 PM
Dinner at 8 PM
Sleeps at 9 PM
" Takes Alcohol either in the morning at 10 am or 7 pm in the evening"
PERSONAL HISTORY
Diet: mixed
Appetite: normal
Bowel and bladder movements :Normal
Sleep: adequate
No known allergies
Addictions : chronic alcholic since 30 years
FAMILY HISTORY
No significant family history
TREATMENT HISTORY
Was on glimiperide for 2 months after getting diagnosed with DM, and stopped using after that, later after 2 months He was on insulin(2.5IU) ,but was not taking insulin regularly
GENERAL EXAMINATION
•Patient is examined in a well lit room after obtaining consent
•Patient is conscious, coherent, cooperative.
Well built and well nourished.
•Mild Pallor
•Icterus,clubbing, cyanosis, koilonychia, edema are absent
•VITALS
Temp- Afebrile
Bp-90/60 mm hg
PR- 82bpm
RR-18CPM
Spo2- 96% on RA
GRBS : 550mg/dl
SYSTEMIC EXAMINATION
RS- bilateral air entry present
CVS : S1, S2 + no murmurs
P/A- soft and non tender
bowel sounds present
CNS : No focal neurological defeicit
HMF intact
Power in B/L upper and lower limb Is 5
Reflexes are present with B/L plantars and flexors
INVESTIGATIONS :
*Fever chart
*X-Ray Chest PA view
*HbA1c
*Liver Function Test
*Blood Urea
*Serum Creatinine
*Serum Potassium
*CUE
*CBP
*ECG
Chronic Alcoholism with Uncontrolled Diabetes Milletus 2 with Post Herpetic Neuralgia
*TREATMENT :
√T.THIAMINE PO/OD
√ T. GLIMI - M₁ PO/TIC
√ 70 PROFILE GRBS MONITORING
√ Pre Breakfast , 2hrs After Breakefast
√ Pre Lunch, 2hrs after LunchLunch
√ Pre dinner, 2hrs after dinner
√ 2 AM in the morning
√ INJ HAI 6 Units S/C
√ Pregaba -m 75mg/PO/ HS
√ Paracetmol 650mg since 3/8/22
√ T.Ultracet 1/2 tab/PO/QID
√ T.Optineuron amp in 100ml NS/IV/OD
√T.Pantop 40mg /PO/OD
27/7/22
{ 11PM -- 550 mg/dl -- 6 Units HAI given
2 AM -- 247 mg/dl
4 AM -- 47 mg/dl -- 25%D given }
28/7/22
{8am - 100 - TAB.Glimi 2.5 mg ,Metformin 1gm
10am - 85 mg/dl - 2 idly
2pm - Hi - 6U HAI given
4pm - 474
7pm - High - Glimi 2.5 mg,Metformin 2 gm
10pm - 532 mg/dl }
29/7/22
{ 8am - 312 - Glimi 2.5mg ,metformin 1gm
10am - 461
1 pm - 397 - 4U HAI
4pm - 416
7pm - Hi - 4U HAI ,4U NPH
10pm - 404 }
30/07/22
{ 2 am - 355
8 am - 466 - Glimi 2.5 mg,metformin 0.5mg
10pm - Hi - Glimiperide 4 mg,metformin 1gm
12pm - 321 -HAI 4units SC
3pm - 325
7pm - 466 - Tab.Glimi 2.5mg
Tab metformin 1g/dl }
31/07/22
{ 12am- Hi - HAI 4U ,NPH 5U
4am - 177
8am - 239
10pm - 348 Glimiperide 4mg,metformin 1gm
1am - 385
2pm- 324
4pm- 528 Glimi 4mg metformin 1gm
10pm-345 }
01/08/22
{ 2am- Hi Glimi 4mg metformin 1gm
8am-288
10am-352
Ondansetron 4mg given 2episodes of vomitings
1pm-200
4pm-394
8pm-338 - Glimi 4mg metformin 1gm
11pm -333 }
02/8/22
{ 2am - 336
8am-155
Glimiperide 4 mg,metformin 1gm
12 pm -318
2 pm -281
4 pm - 470
8 pm - 391
10 pm 477 Glimi 4mg,metformin1mg }
3/8/22
{ 2am - 362
8 am - 135
Glimiperide 4mg,metformin 1mg
12pm - 300
8pm - 532 - Glimi 4mg ,metformin 1mg
10pm - 411 }
4/8/22
{ 2am - 320
8am - 176
Glimiperide 4mg,metformin 1mg
2 idly
11am 528
1 30 pm - 368
3 pm - 388
4pm - 363
8pm - 515
Glimiperide 4mg,metformin1mg
10:30pm - 563 }
5/8/22
{ 2am - 374
8am - 194
Glimiperide 4mg,metformin 1mg
10am - 328
1pm - 181
2pm - 363
8pm - 384
Glimiperide 4mg,metformin 1mg
10:30pm - 560 }
6/8/22
{ 2pm - 370
8am - 342
10am - 247
Glimiperide 4mg ,metformin 1
1pm- 334
10pm - 526
Glimi 4mg,metformin 1mg }
7/8/22
{ 2am - 357
8am - 249
Glimi 4mg , metformin 1mg
10pm - 360
Glimi 4mg , metformin 1mg }
8/8/22
{ 2am - 325
8am - 139 }
Advice at Discharge
√ TAB GLIMIPERIDE 4MG PO BD
BEFORE FOOD [MORNING AND NIGHT]
√ TAB METFORMIN 1000MG PO BD
AFTER FOOD [MORNING AND NIGHT]
√ TAB PREGABALINE M 75MG PO H/S FOR 9 DAYS
√ TAB MVT PO OD FOR 15 DAYS
√ TAB PCM,650MG PO TID FOR 5 DAYS
√ TAB PANTOP 40MG PO OD FOR 5 DAYS
√ TAB ULTRACET 1/2 TAB PO QID FOR 3 DAYS
√ TAB BENFOTHIAMINE PO BD FOR 15 DAYS
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