1801006055 LONG CASE

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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.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

Maheshwari Jagathkari

Roll no 57 

Case report

A 43 year old came to OPD with chief complaints of  wound over the posterior aspect of right foot.

HISTORY OF PRESENTING ILLNESS

Pateint was apparently asymptomatic 6 months back then he notices cracks on the right heel which got infected and progressed to formation of ulcer of present size of about 7*7cm.

There is no history of trauma.

Then he developed swelling of the right lower limb 7 days back in which it gradually attained the present size.

He also complaints of foul smelling discharge from the swelling 7 days back.

History of fever present 1 week back associated with chills, body pains, cough and cold and 

History of 2 episodes of vomiting 1 week back that relieved on medication.

History of polyruia, nocturia present.

No history of polydypsia, polyphagia.

No history of burning micturition, frothy urine.

No history of altered sensorium, giddiness.

PAST HISTORY

No history of similar complaints in the past.

H/o Diabetes mellitus type 2 since 10 years 

(takes Metformin 1000mg in day and 500mg at night)

No H/o Hypertension, CAD, asthma, epilepsy, tuberculosis.

No previous history of blood transfusions.

H/o hemorrhoids surgery 10 years back.

DAILY ROUTINE

Patient wakes up at 6 AM in the morning freshens up drinks tea and has breakfast at around 8:30 AM, goes to work and has lunch at 1:20 PM continues to work drinks tea at 6 PM, dinner at 8:30 PM.

PERSONAL HISTORY

Diet is mixed with decreased appetite since 1 week.

Regular bladder movements

Sleep is adequate.

Addictions

Chronic alcoholic since 20 years 

Tobacco chewing since 20 years

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative, well oriented to time, place and person.

Pedal edema till below knee is present that is of pitting type.

Local rise of temperature over edematous right leg.

 No features indicating the presence of pallor, icterus, cyanosis, clubbing, lymphadenopathy.

Dehydration present at the time of admission - dryness of tongue.

VITALS 

Temperature: Afebrile

Pulse Rate: 96 bpm

Respiratory Rate: 20 cpm

Blood Pressure: 140/90 mm hg

GRBS- 550 mg/dl

SYSTEMIC EXAMINATION

ABDOMINAL EXAMINATION

INSPECTION

Shape - Scaphoid, with no distention.

Umbilicus - Inverted

Equal symmetrical movements in all the quadrants with respiration.

No visible pulsation,peristalsis, dilated veins and localized swellings.

PALPATION

No local rise of temperature

Abdomen is soft with tenderness in the left loin region.

No spleenomegaly, hepatomegaly.

PERCUSSION

Liver span is 12cm.

No hepatomegaly

Fluid thrill and shifting dullness absent.

No puddle sign.

AUSCULTATION

 Bowel sounds present.

No bruit or venous hum

CNS EXAMINATION

HIGHER MENTAL FUNCTIONS:

Intact

CRANIAL NERVE EXAMINATION:

1st : Normal

2nd : visual acuity is normal

3rd,4th,6th : pupillary reflexes present. EOM full range of motion present

5th : sensory intact, motor intact

7th : normal

8th : No abnormality noted.

9th,10th : palatal movements present and equal.

11th,12th : normal.

MOTOR EXAMINATION:

                  Right                  Left

               UL       LL       UL         LL

BULK    Normal Normal Normal Normal      

TONE  Normal Normal Normal Normal 

 POWER 5/5     5/5       5/5       5/5

 SUPERFICIAL REFLEXES:

CORNEAL  present  

CONJUNCTIVAL present 

ABDOMINAL present

 PLANTAR withdrawal

  DEEP TENDON REFLEXES:

                  Right          Left

                UL   LL        UL   LL

   BICEPS 2     2           2      2

  TRICEPS 2    2           2       2

  SUPINATOR 2    2      2      2

   KNEE           2    2      2       2

   ANKLE         1    1       1       1

SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

Crude touch present

pain present

temperature present

DORSAL COLUMN SENSATION:

Fine touch present

Vibration decreased sensation on lower limbs 

Proprioception present

CORTICAL SENSATION:

Two point discrimination present

Tactile localisation present

CEREBELLAR EXAMINATION:

 Finger nose test intact

 Heel knee test intact

 Dysdiadochokinesia intact

 Speech intact

Rhombergs test could not perform

SIGNS OF MENINGEAL IRRITATION: 

Kernigs sign, brudzinski sign, neck rigidity

 absent 

CVS 

S1 S2 heard, no murmurs

RS 

Bilateral air entry present, normal vesicular breath sounds are heard in all areas of lungs, no added breath sounds.

Provisional diagnosis

Diabetic ketoacidosis with chronic non healing ulcer on right foot.

Diabetis mellitus since 10 years.

Investigations

Hemogram 

HB 10.7

TLC 17300

Neutrophils 88

Lymphocytes 7

 Urine for ketone bodies is positive

Serum electrolytes 

Sodium 128mE/l

Pottasium 5.2mE/l

Urine sugars 

4+

ECG

Treatment

IV 0.9% Normal saline 1lt 1st hour followed by 500ml/hr next 2 hours

Give 6l within 24 hrs

Inj HAI 6u IV stat

Infusion HAI infusion 1ml(40U) in 39 ml normal saline

GRBS monitoring hourly

Inj metrogyl 500mg IV TID

Inj pantop 40mg OD