1801006073 - LONG CASE

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 42 year old male patient resident of suryapet who is labourer by occupation came with the cheif complaints of
   Wound over the posterior aspect of right foot since 6 months and swelling of right lower limb since 7 days .

History of presenting illness:
Patient was apparently asymptomatic 6 months back then he had wound over posterior aspect of right foot initial he noticed cracks over the heel then the wound started to grow after few days .
Later he developed swelling of right lower limb below knee since 7 days with local rise of temperature below the knee which was insidious in onset, gradually progressed from ankle to knee.
History of purulent discharge from the wound since 1 day.
He also had history of fever  with chills for 1week .
He had vomiting  which was non bilious 2 episodes per day he went to local hospital took medication which subsided 3 days back.
H/O polyuria 10 times in a day, nocturia
No h/O polydipsia,polyphagia
No h/O burning micturition.
No h/O trauma
No h/o giddiness ,altered sensorium, drowsiness 

PAST HISTORY:
Known case of type 2 DM since 10 years (tab Metformin 1000 msg in day and 500 msg in night).
H/O hemorrhoids surgery 10 years back during this period had test for glucose and noted diabetic since then.
10 years back he met with an accident which caused fracture in the  left lower limb and treatment was taken.
Not a know case of Hypertension, TB, asthma , Coronary artery disease, Epilepsy.

PERSONAL HISTORY:
Decreased appetite since 1 week due to vomitings.
Diet : mixed
Bowel habits are regular
Polyuria present.
Sleep : inadequate
Addictions:
Chronic alcoholic since 20 years
Gutka chewing since 20 years.

GENERAL EXAMINATION 
Patient is consious, coherent cooperative moderatly built and nourished
Pallor: present
Icterus: absent
Cyanosis: absent 
Clubbing: absent 
Lymphadenopathy : absent
Pedal Edema : present 
Right lower limb present till knee
Left lower limb present over the ankle region.
Vitals:
Temperature: afebrile
Pulse rate : 96 bpm
Respiratory rate : 20cpm
Blood pressure:150/ 90 mm of hg
GRBS- 200 mg/dl
(On admission yesterday to the hospital uncontrolled blood sugar was present on treatment today he had around 200mg/dl)
On 15/3/23
9pm 519 mg/dl
10pm 365 mg/dl
11 pm 297 mg/dl
12pm 244 mg/dl
1am 133 mg/dl
2 am 75 mg/dl
3 am 71 mg/dl
4am 113 mg/dl
5am 183 mg/dl
6 am 226 mg/dl


Systemic examination:
CVS: S1 S2 heard no murmurs were heard
Respiratory system: bilateral air entry present
CNS : no focal neurological deficits
Per abdomen examination:
Soft,non tender ,no organomegaly
Bowel sounds heard.

Investigations:
Complete urine examination
Colour:pale yellow
Appearance: clear 
Albumin : present 
Sugar: present
Urine ketone bodies: positive 
Hemogram:
Hemoglobin:10.7gm/dl
Increased neutrophils, lymphocytes
RBC count 3.54 million/cumm
Smear:
RBC normocytic normochromic
WBC increased on smear
No hemoparasites were present
Blood sugar random: 419 mg/dl
Blood urea 49mg/dl
Serum creatinine:2 msg/dl
 Arterial blood gas:
pH-7.392
pCO2-25.7(35-45 mm hg)
pO2- 88 mm hg (12-17.5)
Electrolytes
Sodium 126mmol/L
Potassium 3.2mmol/L
Calcium 0.63mmol/L(1.15-1.29)


Provisional diagnosis:
Diabetic ketoacidosis  secondary to non compliance to insulin with non healing ulcer and known case of diabetes mellitus type2 since 10 years 

Treatment:
Nil by mouth
Inj HAI 6U/IV/STAT
IV Fluids - NS
1st hour 1 lit
2nd hour 500ml
3rd hour 500 ml
Then 250ml/hr till 24 hours
On 16/3/23
IV Fluid flusodex at 100 ml /hr
Human actrapid insulin infusion at 3 ml/hr
Inj metrogyl 500 mg IV/TID
Inj pan 40 mg PO/OD
Inj thiamine 200 nv in 100ml NS BD
strict output monitoring
GRBS- monitoring hourly .

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