Case of 48 yr old male with uncontrolled sugars

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box. 


A 48 yr old male welder by occupation came to opd

Chief complaints

Fever since -    4 days 

Chest pain -     5 days


HOPI

Patient was apparently asymptomatic 4 days back then he developed fever which is intermittent and associated with chills and rigor, no burning micturation 

Chest pain on and off and non radiating

Past history  

Patient was K/C/O diabetes mellitus since 4 yrs and on inj MIXTARD 

Patient was having complaints of weight loss, fever 4 yrs ago and diagnosed with pulmonary Kochs and

Used ATT for 6 months.

After using ATT for 2 months patient had 1 episode of seizure then came to our hospital and diagnosed with high sugars and then insulin started

Patient takes insulin regularly

Patient had complaints of tingling sensations of B/L lower limbs since 1 yr whenever he has those symptoms he used to think due to night dose of insulin and he used to skip night insulin dose.

No complaints of vomitings, loose stools, cough and sob


Personal history  

Diet -       Mixed 

Appetite - Normal 

Bowel and bladder - 

Sleep - adequate 

Addictions - no 


GENERAL EXAMINATION 

Patient is conscious, coherent and cooperative

Pallar -   Absent 

Icterus -   Absent

Cyanosis -   Absent

Clubbing -   Absent

Lymphadenopathy -   Absent 


Vitals 

Temperature - 99.6

PR - 86 bpm 

RR - 18 cpm 

SpO2 - 98%

GRBS -702 mg/dl


SYSTEMIC EXAMINATION 


Cardio vascular system

S1 S2 +

Respiratory system 

Bilateral air entry - present . 

P/A  

SOFT NONTENDER

CNS  
NAD

Investigations

Hb 10.5
TLC 10,200
PLT 1.50 
ESR 90

RBS 702  

CUE
ALB ++
SUGAR ++++
PUS CELLS 24 TO 26

CRP 2.4 

LFT
TB 1.01
DB 0.26
AST 15 
ALT 19
ALP 168
TP 6.3
ALB 3.2

RFT
B UREA 48
S CREAT 2.0

Serum electrolytes 
SODIUM 129
K 4.1
Cl 99
24 hrs urine creat 0.53g/day
Protein 329 mg/day


Fever chart



Ecg

Chest x ray



Clinical images
Usg



Provisional diagnosis 

FEVER UNDER EVALUATION  WITH UNCONTROLLED SUAGRS? DIABETIC NEPHROPATHY.


    Treatment

1 .IVF NS RL @ 50ML /HR
2. TAB NITROFURANTOIN 100 mg po BD
3.TAB .DOLO 650mg po BD
4.GRBS monitoring















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