camp case 4/5/2024.
Camp case
80 yr old male
CHEIF COMPLAINTS:
Came with c/o giddiness since 15 days.
HOPI:
Pt was apparently asymptomatic 15 days back and then had giddiness which was episodic daily once ,mrng before lunch a/w blurring of vision during that episode and relieves after taking food.
H/o tingling and numbness of lower limbs since 10 yrs extending from tip of toes to shin of tibia
H/o burning sensation of feet since 5 yrs
H/o chest pain since 4 days , pricking type ,on and off ,no precipitating factors
H/o loose stools for one day which was one week ago and subsided on medication.
No h/o polyuria polydypsia
No h/o decreased urine,output burning micturition
No h/o fever,pedal edema ,facial puffiness
No h/o constipation,
No h/o similar complaints at night times
No h/o sob , palpitations
PAST HISTORY
K/c/o Htn on tab telma am -40/5
K/c/o dm on INJ MIXTARD 20UBBF ,15U BD
K/C/O CKD SINCE 13 yrs
K/C/O HFPEF 2° to CAD since 1 month
H/O stable angina 1 month ago
No other comorbidities
PERSONAL HISTORY:
Married
Diet: mixed
Appetite: decreased
Sleep: adequate
Bowel movements: constipation
Bladder habits: regular
Addictions: alcoholic stopped 8 yrs back and stopped smoking 8 yrs back.
Allergies:no
GENERAL EXAMINATION
O/e
Pt c/c/c
Temp - afebrile
Pr - 80bpm
Bp -130/70 mmHg
No pallor
No icterus
No cyanosis
No clubbing
No pedal odema
No lymphadenopathy
SYSTEMIC EXAMINATION:
Cvs -S1,S2 heard
Rs - Bae +nt,nvbs
Grbs -300
P/a - soft ,nt
CNS - tone -normal
Power 5/5 in all limbs
Reflexes -
B. +1. +1
T. +2. +2
S- - -
K. +1 +1
A. - -
P - F F
Senosory system
Fine touch - intact
Crude touch - intact
Vibration sense - decreased in lower limbs
Investigations
TREATMENT:
4/5/2024
1)T.TELMA AM 40/5 PO/OD
2)T.PREGABALIN 75mg PO/OD
3)T.ULTRACET PO/BD
4)INJ.HAI SC TID ACCORDING TO GRBS
5)GRBS 7 HOURLY PROFILE
6)BP MONITORING 4th HOURLY
7)INFORM SOS
8)T.DYTOR PLUS 10/25 PO/OD
9)T.ECOSPRIN AV 75/10 PO HS
10)T.PAN 40MG PO/OD
11) STRICT DIABETIC DIET
5/5/2024
1)T.TELMA AM 40/5 PO/OD
2)T.PREGABALIN 75mg PO/OD
3)T.ULTRACET PO/BD
4)INJ.HAI SC TID ACCORDING TO GRBS
5)GRBS 7 HOURLY PROFILE
6)BP MONITORING 4th HOURLY
7)INFORM SOS
8)T.DYTOR PLUS 10/25 PO/OD
9)T.ECOSPRIN AV 75/10 PO HS
10)T.PAN 40MG PO/OD
PROVISIONAL DIAGNOSIS:
Peripheral neuropathy (sensory and motor) secondary to Diabetes mellitus .
Diabetes mellitus since 30 years
Hypertension since 30 years.
Chronic kidney disease since 13 years secondary to??DM.
H/o stable angina one month back
HFPEF
BPH.
Admission Date : 4/5/2024
Discharge Date : 6/5/2024
Ward:MMW
Unit:II
Diagnosis :
PERIPHERAL NEUROPATHY (SENSORY &MOTOR)
DIABETES MELLITUS SINCE 30 YEARS
HYPERTENSION SINCE 30 YEARS
CHRONIC KIDNEY DISEASE SINCE 13 YEARS
BENIGN PROSTATIC HYPERPLASIA
Case History and Clinical Findings
C/O GIDDINESS SINCE 15 DAYS HOPI-
PATIENT WS APPARENTLY ASYMPTOMATIC 15DAYS AGO THEN DEVELOPED EPISODES OF GIDDINESS A/W BLURRING OF VISION A/W SWEATING RELIEVED AFTER TAKING FOODDAILY ONE EPISODE
H/O CHEST PAIN SINCE 4DAYS PRICKING TYPE ON AND OFF ,NO PRECIPITATING FACTORS H/O TINGLING AND NUMBNESS OF LOWER LIMBS SINCE 10 YEARS EXTENDING FROM TIP OF TOES TO SHIN OF TIBIA
H/O BURNING SENSATION OF FEET SINCE 5 YEARS
H/O LOOSE STOOLS FOR 1 DAY WHICH WAS ONE WEEK AGO AND SUBSIDED ON MEDICATION FOLLOWED BY PAIN ABDOMEN IN UMBLICAL REGION SINCE THEN NO H/O LOSS OF APPETITE SINCE 1 WEEK
NO H/O POLYURIA,POLYDIPSIA NO H/O PALPITATIONS ,SOB
NO H/O HYPOGLYCEMIC EVENT AT NIGHT
NO H/O DECREASED URINE OUTPUT ,
BURNING MICTURITION
NO H/O FEVER, PEDAL EDEMA ,FACIAL PUFFINESS
PAST H/O-
K/C/O HTN SINCE 30YRS AND ON T.TELMA AM 40/5
K/C/O DM SINCE 30 YRS ON INJ MIXTARD 20U(BBF)-X-15U(BBF) K/C/O CKD SINCE 13 YEARS
ON EXAMINATION
PT IS CONSCIOUS, COHERENT,COOPERATIVETEMP-AFEBRILE
PULSE RATE 80 BPM BP 110/80 MMHG
CVS-S1 S2 HEARD NO MURMURS RS- BAE PRESENT NVB
P/A-SOFT,NON TENDER
OPHTHALMOLOGY REFERRAL I/V/O -DIABETIC RETINOPATHY IMPRESSION -NORMAL FUNDUS STUDY
Investigation
NameValueRangeNameValueRangeRFT 04-05-2024 04:15:PM UREA37 mg/dl50-17 mg/dlCREATININE2.6 mg/dl1.3-0.8 mg/dlURIC ACID6.7 mmol/L7.2-3.5 mmol/LCALCIUM10.0 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.7 mg/dl4.5-2.5 mg/dlSODIUM137 mmol/L145-136 mmol/LPOTASSIUM4.6 mmol/L.5.1-3.5 mmol/L.CHLORIDE102 mmol/L98-107 mmol/LLIVER FUNCTION TEST (LFT) 04-05-2024 04:15:PM Total Bilurubin0.56 mg/dl1-0 mg/dlDirect Bilurubin0.20mg/dl0.2-0.0 mg/dlSGOT(AST)12 IU/L35-0 IU/LSGPT(ALT)10 IU/L45-0 IU/LALKALINE PHOSPHATASE179 IU/L119-56 IU/LTOTAL PROTEINS6.9 gm/dl8.3-6.4 gm/dlALBUMIN4.0
gm/dl4.6-3.2 gm/dlA/G RATIO1.42HBsAg-RAPID04-05-2024 04:15:PMNegative Anti HCV Antibodies
- RAPID04-05-2024 04:15:PMNon Reactive COMPLETE URINE EXAMINATION (CUE) 04-05-2024 04:15:PM COLOURPaleyellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGAR+++BILE SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS2-3RED BLOODCELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilPOST LUNCH BLOOD SUGAR04-05-2024 04:17:PM196 mg/dl140-0 mg/dlABG 05-05-2024 09:12:AMPH7.33PCO229.7PO290.0HCO315.3St.HCO317.2BEB-9.1BEecf-9.4TCO231.7O2 Sat96.1O2
HB-11.1TLC-6700PLT-2.80RBC-3.55
HBA1C-7.1 % FBS-70 MG/DLPLBS-196MG/DLSPOT UPCR-
SPOT URINE PROTEIN -6.0 SPOT URINE CREATININE 87.5 RATIO 0.06
2DECHO-EF-65 %
IVC-0.7CM COLLAPSINGTRIVIALTR+/AR+ ,NO MR
NO RWMA ,NO AS/MS SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION
GRADE 1 DIASTOLIC DYSFUNTION ,NO PAH/PE/LV CLOT USG ABDOMEN &PELVIS (06/5/24)
IMPRSSION -B/L GRADE 1 RPD CHAGES IN KIDNEY B/L RENAL CORTICAL CYSTS
GRADE 1 PROSTATOMEGALY
Treatment Given(Enter only Generic Name)
T.TELMA -AM 40/5 PO/OD T.DYTOR PLUS 10/25 PO/ODT.PREGABALIN 75MG PO/HST.ECOSPORIN AV 75/10 PO HS T.PAN 40MG PO/OD
INJ HAI S/C TID ACC TO GRBS T.SHELCAL -XT PO/ODTAB.NODOSIS 500MG PO/OD
Advice at Discharge
T.TELMA -AM 40/5 PO/OD CONTINUE
T.DYTOR PLUS 10/25 PO/OD X 1 MONTH T.PREGABALIN 75MG PO/HS X 15 DAYST.ECOSPORIN AV 75/10 PO HS X CONTINUE T.PAN 40MG PO/OD X 5DAYS
T.SHELCAL -XT PO/OD X 15DAYS TAB.NODOSIS 500MG PO/OD X 1MONTHINJ HAI S/C TID 8U-10U-8U
FOOD PLATE
5/5/24
6/5/24
Admission Date: 18/05/2024
Discharge Date: 20.5.24
Ward:GM MW
Unit: 1
Diagnosis
ACUTE GASTRITIS
K/C/O DIABETES MILLETUS SINCE 30 YEARS K/C/O HYPERTENSION SINCE 10 YEARS CHRONIC KIDNEY DISEASE STAGE 4
Case History and Clinical Findings
CHIEF COMPLAINTS :
DIFICULTY IN BREATHING SINCE 2 MONTHS, HARD STOOLS SINCE 1MONTH , BLOATING OF ABDOMEN SINCE 1MONTH , GIDDINESS SINCE 1 WEEK
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS BACK THEN HE DEVELOPED DIFFICULTY IN BREATHING WHICH IS OF GRADE 2 WITH NO AGGREVATING AND RELEIVINGFACTORS
COMPLAINTS OF HARD PELLET STOOLS WITHOUT ANY BLOOD TINGE SINCE 1 MONTH C/O BLOATING OF ABDOMEN SINCE 1 MONTH
N/H/O CHEST TIGHTNESSN/H/O ORTHOPNEA PND
N/H/O BLEEDING MANIFESTATIONS PAST HISTORY :
K/C/O HYPERTENSIOPN ON TAB.CINOD 10 MG BD SINCE 10 YEARS K/C/O DM SINCE 30 YEARS ON INJ.HAI 8-10-8
K/C/O CKD SINCE 13 YEARS ON NODOSIS 500 MG
PERSONAL HISTORY:
DIET: MIXEDAPPETITE:NORMAL
BOWEL AND BLADDER MOVEMENTS: REGULAR. NO KNOWN ALLERGIES AND ADDICTIONS. FAMILY HISTORY:NOT SIGNIFICANT. GENEREAL EXAMINATION:
PATIENT IS C/C/CTEMP: AFEBRILEPR: 80 BPM
RR: 20 CPM
BP: 110/70 MMHGSPO2: 98 @ RA.
SYSTEMIC EXAMINATION:
CVS: S1 S2 HEARD. NO MURMURSRESPIRATORY SYSTEM: BAE+
P/A- SOFT, NON TENDER.
CNS- NO FOCAL NEUROLOGICAL DEFECTS.
OPTHALMOLOGY REFERRAL ON 20/5/24 I/V/O FUNDOSCOPIC EXAMINATION. NO EVIDENCE OF DIABETIC OR HYPERTEMDOVE RETINOPATHY CHANGES.
COURSE IN HOSPITAL:
A 75 YEAR OLD MALE CAME WITHDIFICULTY IN BREATHING SINCE 2 MONTHS, HARD STOOLS SINCE 1MONTH , BLOATING OF ABDOMEN SINCE 1MONTH , GIDDINESS SINCE 1 WEEK.
PATIENT WAS DIAGNOSED AS ACUTE GASTRITIS K/C/O DIABETES MILLETUS SINCE 30 YEARS K/C/O HYPERTENSION SINCE 10 YEARS, CHRONIC KIDNEY DISEASE STAGE 4. ALL THE NECESSARY INVESTIGATION WHERE SENT.
OPTHALMOLOGY REFERRAL ON 20/5/24 I/V/O FUNDOSCOPIC EXAMINATION. NO EVIDENCE OF DIABETIC OR HYPERTEMDOVE RETINOPATHY CHANGES. PATIENT TREATED CONSERVATIVELY AND ACCORDINGLY.
PATIENT SYMPTOMS SUBSIDED.
PATIENT DISCHARGED IN HEMODYNAMICALLY STABLE STATE.
Investigation
NameValueRangeRFT 18-05-2024 03:46:PM UREA39 mg/dl50-17 mg/dlCREATININE2.4 mg/dl1.3-0.8 mg/dlURIC ACID4.4 mmol/L7.2-3.5 mmol/LCALCIUM9.8 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.1 mg/dl4.5-2.5 mg/dlSODIUM139 mmol/L145-136 mmol/LPOTASSIUM4.3 mmol/L.5.1-3.5 mmol/L.CHLORIDE105 mmol/L98-107 mmol/LLIVER FUNCTION TEST (LFT) 18-05-2024 03:46:PM Total Bilurubin0.59 mg/dl1-0 mg/dlDirect Bilurubin0.14mg/dl0.2-0.0 mg/dlSGOT(AST)27 IU/L35-0 IU/LSGPT(ALT)16 IU/L45-0 IU/LALKALINE PHOSPHATASE162 IU/L119-56 IU/LTOTAL PROTEINS6.6 gm/dl8.3-6.4 gm/dlALBUMIN4.08 gm/dl4.6-3.2 gm/dlA/G RATIO1.62COMPLETE URINE EXAMINATION (CUE) 18-05-2024 03:46:PM COLOURPaleyellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINTraceSUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS3-4EPITHELIAL CELLS2-3RED BLOODCELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilHBsAg-RAPID18-
05-2024 03:46:PMNegative Anti HCV Antibodies - RAPID18-05-2024 03:46:PMNon Reactive hba1c: 6.6%
Treatment Given(Enter only Generic Name)
1. INJ HAI SC/ TID 4U-6U -4U
2. TAB NODOSIS 500 MG PO/OD 0-1-0
3. TAB ECOSPRIN-A 5/10 PO/HS 0-0-1
4. TAB DYTOR PLUS 10/25 PO/OD @ 10 AM
5. TAB CINOD 10 MG PO/BD 1-0-1 .
6. SYP CREMAFFIN 20 ML PO/HS 0-0-1
Advice at Discharge
1. INJ HAI SC/ TID 4U-6U -4U CONTINUE
2. TAB NODOSIS 500 MG PO/OD 0-1-0 CONTINUE
3. TAB ECOSPRIN-A 5/10 PO/HS 0-0-1 CONTINUE
4. TAB DYTOR PLUS 10/25 PO/OD @ 10 AM CONTINUE
5. TAB CINOD 10 MG PO/BD 1-0-1 CONTINUE.
6. SYP CREMAFFIN 20 ML PO/HS 0-0-1 X 7 DAYS.
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[26/05/24, 8:31:46 AM] Dr.Rakesh Biswas Sir GM KIMS: @919866079206 @917382828731 Is he on 6U of insulin before meals tid?
Can someone update all his post discharge regularly shared insulin taken daily and glucose results through smbg (self monitoring of blood glucose)?
[26/05/24, 9:38:14 AM] Dr.Narsimha Reddy: He Was Discharged on Monday Sir & Asked to Take 4U - 6U - 4U HAI Sir
Tuesday & Wednesday - He took Same dose
Thursday - Morning He Took 4U ; He went Outside & Was busy in Conversation ( General Talks ) with his Village People So Skipped Afternoon & Night Insulin
Friday - FBS was 176 ( Checked in nearby Clinic) So He increased Insulin Dose by 1U ( 5U - 7U - 5U )
Today - FBS was 150 ...He Took 6U HAI
[26/05/24, 9:47:59 AM] Dr.Narsimha Reddy: So Asked to continue 6U -6U -6U & Share his post Meal Sugars 3 days Later.
Current Diet -
Morning- Ragi Java 1 Small Glass
Afternoon- Rice & Curry
Night- Ragi Roti (1-2)
No Habbit of Drinking Tea/Coffee
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