35 year old male with uncontrolled sugars

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Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solveb 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 is welcome.

Case:

This is a case of a 35 year old male with chief complaints of loss of sensation in both limbs below knee and upper limbs below elbows since 6 months.

Daily routine- patient is a labourer by occupation.

He wakes up in the morning at 6 am

Has his breakfast (rice)by 8am 

Goes to work at 9am

Has his lunch at 1pm

He goes back home by 8pm

Patient has been drinking alcohol since he was 15 years old.He has a habit of drinking throughout the day.

He also chews tobacco.

History of presenting illness:

Patient was apparently asymptomatic 4 years back. He then developed stomach pain where he got admitted to hospital when he got diagnosed as having high blood sugar as an incidental finding and started on oral hypoglycemic drugs then since 6 months he stopped taking medications for

 diabetes from then he develop polyphagia, polydypsia 

increased frequency of urination present 

delayed wound healing present weight loss present 

Tingling sensation of both upper & lower limbs present

Loss of sensation present  

Numbness present 

No Burning micturition 

 Loss & sensation initially present in B/L feet which progressed to below knees since he stopped medication 

Past history:

K/C/o DM since 4 years -Stopped Medication since 6 months due to financial constraints

 Not a k/C/O HTN,TB, CAD,  Asthma, epilepsy

Personal history:

Diet: mixed

Apetite: decreased

Bowel and bladder: increased frequency 

Addictions: alcohol since he was 10 years old

GENERAL EXAMINATION:

Patient is conscious,coherent and cooperative, moderately built and moderately nourished.

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: absent

Pedal edema: absent 

Vitals:

Temparature:Afebrile

Pulse:90 bpm

Blood pressure:120/80 mm hg

RR: 19 cpm

Systemic examination:

Cvs: s1 s2 are heard

RS: Bilateral air entry present 

Abdomen:Soft and non tender

CNS:Higher mental functions intact 

Reflexes:.          Rt.                       Lt

     

Biceps.                +.                       +

Triceps.               +.                       +

Supinator.           +.                       +  

Knee.                   +.                       +

Ankle.                  +.                       +

Plantar.                Flexon.              Mute

Investigations:

Provisional Diagnosis:

Uncontrolled sugar secondary to non compliance to OHA

Alcohol dependence syndrome and tobacco dependence syndrome

Diabetic polyneuropathy

Treatment:

 1) IV Fluids NS @ 75 ml/ hr

2) INJ THIAmINE 200mg in l00Ml,NS
8Am -28m - 8Pm

3) INJ OPTINEURON in 100ML NS

70M with Seizures,CVA and uncontrolled sugars,tracheostomised

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

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

CASE HISTORY:-

Chief complaints:-

H/o involuntary movements of left upper and lower limbs followed by unconsciousness 15 days ago.

Pt was born and brought up in nerada.He lead a healthy childhood living along with his family doing agriculture.He was illiterate,started farming at around 15 years of age and at 17 yrs of age started smoking due to peer pressure.At 25 years of age he got married to his wife and had 3 children .He had no health issues.20 years ago his middle child met with a Road traffic accident after that incident to allievate emotional distrubance he started consuming alcohol since then he consumes around 90 to 180ml of alcohol twice or thrice a week.He remained asymptomatic until 3 years ago then he had h/o generalised weakness and fever for which he went to hospital and diagnosed to have diabetes aa nd started on medication but due to financial reasons he used them irregularly and 1 and 1/2 yr ago one day he had weakness of right upper and lower limbs for which he was taken to nearby hospital there they diagnosed him of having CVA(right hemiparesis).He used medication and within 2 months his condition got improved and began to walk and do his daily activities.He discontinued medication after that.

15 days ago on his visit to in laws home he binged on alcohol for 3 days in sequence,decreased food intake and had an episode of involuntary movements of left upper and lower limbs followed by unconsciousness.They took him to hospital where he was found to have hypoglycemia.2 days later he got intubated i/v/o ?status epilepticus and later tracheostomised 3 days ago.

They brought the patient to casuality tracheostomised 

Past history in brief:-KNOWN CASE OF CVA SINCE 1 and 1/2YEAR, USING MEDICATION.

KNOWN CASE OF TYPE 2 DM SINCE 3 YEARS, ON IRREGULAR MEDICATION

NOT A K/C/O HTN, CAD, BRONCHIAL ASTHMA, THYROID DISORDER, TB, EPILEPSY

Personal history:-

MIXED DIET

APETTITE NORMAL

REGULAR BOWEL AND BLADDER

KNOWN ALCOHOLIC SINCE 20 YEAR

KNOWN SMOKER SINCE 15 YRS OF AGE

NO SLEEP DISTURBANCES.

FAMILY HISTORY:-NOT SIGNIFICANT

Vitals:-

PR:-98bpm

Bp:-130/80mm hg

Rr:-24cpm

Spo2:-98%

Fio2- 30,%

General examination:-PATIENTS IS ON MECHANICAL VENTILATOR.

MODERATLY BUILT AND NOURISHED 

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPTHY, 

EDEMA OF RIGHT UPPER LIMB SINCE 4 DAYS

Rs:-BLAE,Crepts+ in rt MA,LMA

Cvs:-S1S2 +,No murmurs

CNS:-

Pt is on drowsy but arousablestate

GCS:-E4VTM5

Tone rt  lt

UL ↓.       ↑

LL ↓.       ↑

Power couldnt be elicited

Reflexes

      B.    T.   S.  K.   A.  P 

Rt.  2+. -     -      -     -   flexion

Lt.   2+. 2+. -   +.    -   flexion

Pupils- b/l normal size and normal light reflex

Corneal and conjunctival reflex-present b/l

Doll's eye reflex absent

No neck stiffness 

Jaw jerk absent

Per abdomen:-soft,NT

Grbs:-133mg/dl

Investigations:-

Hemogram

Rft

Abg

Et tube c/s

blood c/s

tracheostomy c/s

Serial hemogram reports

serial RFT

LFt

ABGCUEFINAL DIAGNOSIS

RECURRENT CVA WITH ( PONTINE INFARCT) WITH ISCHEMIC SEIZURES  WITH SEPSIS; NON OLIGURIC AKI (RESOLVED) WITH TYPE I RESPIRATORY FAILURE ? HOSPITAL ACQUIRED PNEUMONIA; GRADE II BED SORES @ GLUTEAL REGION; K/C/O CVA SINCE 1 AND ½ YEARS; K/C/O TYPE II DM SINCE 3 YEARS, S/P TRACHEOSTOMY DAY-12; DENOVO HTN+ , POST INTUBATION DAY20

TREATMENT GIVEN:-

RT FEEDS

IV FLUIDS 2 PINT NS @ 75 ML/HR

INJ. PIPTAZ 2.25gm IV QID FOR 7DAYS

INJ PANTOP 2.25 GM 40 mg IV/OD

INJ. LEVIPIL 1 G IV/BD

INJ. GLYCOPYRROLATE 2 ML IV/SOS

INJ. HAI SC/ TID BEFORE MEAL 6U-6U-4U

INJ. NEOMOL 1G IV/ SOS (IF TEMP> 101 F)

INJ. OPTINEURON 1 AMP IN 100 ML NS

TAB. CLOPITAB 75 MG PO/HS RT/HS

TAB. STROCIT PLUS 800/500 MG RT/BD

TAB. CINOD 10 MG RT/ OD

 TAB. MET-XL 12.5 G RT/OD

TAB THIAMINE 200 MG IN 100 ML NS IV/BD

TAB. LIBRIUM 25 MG RT/TID

OINT. MEGAHEAL FOR LOCAL APPLICATIN OVER BEDSORE.

GRBS 7 POINTS PROFILE

AIR BED

POSITION CHANGE 2nd HOURLY

DAILY BEDSORE DRESSING WITH NEOSPORIN POWDER

PHYSIOTHERAPY OF ALL LIMBS

WATCH FOR SEIZURE ACTIVITY

LIMB ELEVATION