35 year old male with Uncontrolled Sugars
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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 35 years old male farmer by occupation presented with the chief complaints of-
1) Burning micturition since 1 year
2)Fever since 1 week
3)vomitings 5 days ago.
History of presenting Illness :
Patient was apparently asymptomatic 1 week ago.Then he developed high grade fever which was insidious in onset, gradually progressive in nature, on and off fever , associated with sweats , associated with chills and rigors.Temperature raised during afternoon persisted till midnight and lowered later . No aggravating factors and relieved on medication .
H/o 4 -5 episodes of vomiting on each day(2 days) 5 days before admission to hospital . Vomitings had contents as food,non projectile,non blood stained ,non foul smelling and they are after intake of meal.
H/o burning micturition since 1 year associated with white colour urine since 3 days.
H/o generalised weakness since December 2022 but it became severe 1 week ago where patient was unable to move.
H/o constipation since 1 week ( last stool passed on 13/4/2023) .
H/o Anorexia since 5 days .
No H/o fever rash,joint pain ,myalgia,dyspnea, palpitations, diarrhoea,blood in stools, pharyngitis.
No H/o decreased urine output ,increased frequency,increased urgency, hematuria.
No h/o fatigue, nausea, Anorexia, pruritus,altered sensorium ,hiccoughs.
Past history
K/c/o Diabetes mellitus since 4 months .
K/c/o Anemia since 4 months .
H/o urinary tract infection (December 2022)
Pus cells were >500/ HPF on 16 dec 2022.
Not a known case of Hypertension, Asthma, thyroid disorders,TB, Epilepsy.
Personal History
Mixed diet
Appetite reduced
Disturbed sleep
Bladder - Burning micturition associated with white color urine
Bowel movements - irregular
(Constipation- 9-4-2023 ➡️ 13 -4-2023) - less than 2 episodes of stools in week.
Family history:
His father is one-sided paralysed.
Treatment History
Patient was on insulin (inj ) for months but shifted to oral hypoglycemic agents before 1 month of admission at our hospital.
General Examination.
Patient is conscious, coherent and co -operative.
Patient is lean.
Pallor - present.
Icterus- absent
Clubbing - absent
Cyanosis - absent
lymphadenopathy - absent
Edema - absent
Vitals
Temperature - 100.4 ° F
BP- 120/80 mm hg
PR - 73bpm
RR - 15cpm
GRBS - 267 mg/dl
Systemic Examination:
CNS EXAMINATION:
Higher mental functions intact
Motor system
Right. Left
Bulk: Normal Normal
Tone:
Upper Limb. Normal. Normal
Lower Limb. Normal Normal
Reflexes: biceps. +. +
Triceps. +. +
Supinator. +. +
Knee. +. +
Ankle. + +
Plantar mute Mute
Sensory examination
Spinothalamic tract
Crude touch Right Left
Upper limb Normal Normal
Lower limb Normal. Normal
Pain
Upper limb Normal Normal
Lower limb Normal. Normal
Temperature
Upper limb Normal Normal
Lower limb Normal. Normal
Posterior column tract
Fine touch
Upper limb Normal Normal
Lower limb Normal. Normal
Vibrations Normal in upper and lower limbs
Cortical Tract
Tactile localisation
Upper limb Normal Normal
Lower limb Normal. Normal
Stereognosis - Normal
meningeal signs absent
PER ABDOMEN EXAMINATION :
On inspection
Shape of abdomen : flat
Umbilicus : inverted
Movements of abdomen wall with respiration
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
On palpation
No local rise of temperature
Inspectors findings are confirmed
Soft and non tender
No palpable mass
Liver and spleen not palpable
On percussion
Resonance note heard
On auscultation
Bowel sounds heard
RESPIRATORY SYSTEM
Inspection:
Trachea appears to be Central
shape of chest - elliptical
Movements of chest appear to be bilaterally equal
No scars , sinuses present.
No drooping of shoulder
No engorged veins , swellings seen
No hallowing seen
No crowding of ribs
Palpation:
All inspectory findings are confirmed
No rise of temperature
No tenderness
Trachea is central.
B/L chest movements are equal
No swelling and palpable masses are felt
vocal fremitus are normal
Apex beat is felt at 5th ICS 1cm medial to mid clavicular line.
Percussion:
Resonant note heard in all regions.
Auscultation :
Normal vesicular breath sounds heard.
CVS EXAMINATION
Inspection-
No raised JVP
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse at 5th intercostal space
Palpation-
Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line
Percussion -
Right and left borders of the heart are percussed
Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard
PROVISIONAL DIAGNOSIS:
Uncontrolled sugars due to non compliance to medication.
Anemia
Investigations :
ECG
GRBS on 14 /4/2023.
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