General Medicine Final Practicals Examination - LONG CASE

KP Pranay

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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan.

LONG CASE

A 46 year old male came to hospital with the chief complaints of 

-burning micturition since 10 days

-vomiting since 2 days (3-4 episodes)

-giddiness and deviation of mouth since 1 day

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10years back, he complained of polyuria for which he was diagnosed with Type 2 diabetes mellitus,he was started on OHAs, 3years back OHAs were converted to insulin.

20days back he developed vomiting containing food particles, non bilious,non foul smelling(3-4 episodes),later he complained of giddiness and deviation of mouth for which he was brought to our hospital and his GRBS was recorded high value for which he was given NPH 10U and HAI 10U.

No history of fever/cough/cold.

No significant history of UTI's.




Past history:

10years back- patient complained of polyuria for which he was diagnosed with Type 2 Diabetes Mellitus he was started on oral hypoglycemic agents(OHA) 10years back

3years back- OHAs were converted into Insulin

3years back- he underwent cataract surgery

1year back- he had injury to his right leg, which gradually progressed to non healing ulcer extending upto below knee and ended with undergoing below knee amputation due to developement of wet gangrene.

Delayed wound healing was present- it took 2months to heal

Not a k/c/o Hypertension, Epilepsy,Tuberculosis, Thyroid

Not on any medication

No history of blood transfusion 

PERSONAL HISTORY:

Diet - Mixed

Appetite- normal

Sleep- Adequate 

Bowel and bladder- Regular

Micturition- burning micturition present

Habits/Addiction: AlcoholNot consuming alcohol since 1 yr.

Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.

FAMILY HISTORY:

Not significant

VITALS @ Admission:

BP: 110/80 mmHg

HR: 98 bpm

RR: 18 cpm

Temperature: 99°F

SpO2: 98% on RA

GRBS: 124 mg/dL

GENERAL EXAMINATION:

Pallor: present 

Icterus: Absent

Cyanosis: Absent 

Clubbing: Absent

Lymphadenopathy: Absent

No dehydration

Pallor








Amputated leg



SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard, No murmurs

RS: BAE+, Normal vesicular breath sounds heard

P/A: Soft, Non tender

CNS

Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal

Power: Normal(5/5) in both Upper and Lower limbs

Tone: Normal in both Upper and Lower limbs

No meningeal signs

INVESTIGATIONS:

On admission (19.5.22)



X-Ray


CT Scan




 


Ultrasound report abdomen and pelvis



20.05.22
LDH- 192
24hr Urinary protein- 434
24hrs Urinary creatinine- 0.5

 
Culture report:  Klebsiella Pneumonia positive


Pus cells

21.5.22
Hemoglobin- 6.8g%
TLC- 22,500cells/mm³
Platelets- 1.4lakhs/mm³

Urea- 155mg/dl
Creatinine- 4.7
Uric acid- 7.1
Phosphorus- 2.0
Sodium- 126
Potassium- 2.6
Chloride- 87

22.5.22
Hemoglobin- 7.2
TLC- 17,409
Platelet count- 1.5

Urea- 162
Uric acid- 5.0
Sodium- 125
Chloride- 88

23.2.22



25.5.22


Dj stenting


27.5.22
Hb- 7
TLC- 22,000
Platelet count- 26,000
Urea- 144
Creatinine - 4.8
Uric acid-9.1
Phosphorus- 4.8
Sodium- 135
Potassium- 4.3
Chloride- 98
Fasting blood sugar- 149

29.5.22
Hb- 6.4
TLC- 14,700
Platelet count- 6000
Urea - 149
Creatinine- 4.4
Uric acid- 9.2

PROVISIONAL DIAGNOSIS:
Right emphysematous pyelonephiritis and left acute pyelonephiritis and encephalopathy secondary to sepsis.
H/o of Type 2 Diabetes mellitus since 10years

TREATMENT:

Day 1 to Day 3:
INJ. MEROPENEM 500mg IV BD
INJ. ZOFER 4mg IV TID
INJ. PAN 40mg IV OD
IV Fluids- NS,RL @ 100 mL/hr
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
RT feeds- 2nd hrly 100 mL water

Day 4:
INJ. MEROPENEM 500mg IV BD
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion
IV Fluids- NS,RL @ 100 mL/hr
SYP. POTCHLOR 10 mL in 1 glass of water TID
SYP. MUCAINE GEL 10 mL PO TID
7 point profile
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
RT feeds- 2nd hrly 100 mL water

Day 5 to Day 10:
INJ. MEROPENEM 500mg IV BD (Day 6)
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS
BP/HR/RR/SpO2 charting
Temp charting 4th hrly

Day 11:
INJ. COLISTIN 2.25 MU IV OD(Day 4)
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS

Day 12:
SDP Transfusion done I/v/o low platelet count 
Pre transfusion counts:
Hb:6.2 g/dL
TLC:14700
PLt:6000

Post transfusion counts:
Hb:6.4
TLC:13700
PLt:50000

INJ. COLISTIN 2.25 MU IV OD(Day 5)
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS

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