e log 2

A 36 year old male lecturer by occupation came with complaints of pain in left lower rib since 1 week and vomitings since 3 days. 

Patient was apparently asymptomatic 7 years ago and then he had an episode of giddiness and fall for which he went to the hospital and was diagnosed with Diabetes Mellitus and was started on OHAs. Patient used to go for regular check ups, got FBS, PLBS done which were under control on Metformin. 

Later, he was started on GLIMI M1 and now GLIMI MV2 2-3 months ago. However, he says he hasn’t been regular with his medication since one week. 

3 years ago, patient started binging on alcohol, without consuming any food and developed pain abdomen for whcih he was diagnosed with Acute pancreatitis. He received treatment for 15 days at an outside hospital. 

3 years ago patient had a ?Callus formation/ thickened part on plantar aspect of left foot. He himself used to cut the thickened part with a blade, which turned into an ulcer 1 year ago for which he then underwent debridement. He did his own dressing by using spirit to clean the area and then puts iodine and cotton on it, every alternate day. 

He quit his job and is only staying at home since 2 years but occasionally teaches as a guest lecturer.

2 years ago, He attempted suicide by consuming OP poison and was treated at outside hospital. 

1 n1/2 years ago, he again started binging on alcohol and developed pain abdomen but it was not diagnosed as another episode of acute pancreatitis. 

Since 1 year, he is experiencing burning sensation in his feet, tingling sensation from his foot to his calf. 

He has pedal edema till ankle in his left foot, which is of pitting type which can be seen at the end of the day. 

5 days ago, he fell from his bike and is experiencing pain in his left lower rib since then. Tenderness +

Now, since 3 days he again started binging on alcohol without consuming food and stopped taking OHAs. 

He also has complaints of vomitings since 3 days which were non projectile, non bilious and had food particles as content.  He had one episode of blood in vomitus 3 days back. 

He reports intolerance on drinking water as well, feels nauseous as soon as he consumes water. 

He was diagnosed with Diabetes mellitus 7 years back and was started on Metformin initially, then on Tab, GLIMI MV1 —> Tab. GLIMI MV2 since 2-3 months

O/E:

Temp: 98°F

PR: 104bpm

RR: 18 cpm

BP: 120/80 mm hg

SpO2: 98% on RA 

GRBS: High (>400mg%)

Mild pallor present. 

No icterus, cyanosis, clubbing,  lymphadenopathy. 

Pedal edema present upto ankle in Left foot. 

CVS: S1 S2 +, No murmurs

RS: BAE + 

CNS: 

HMF- intact, conscious 

Cranial nerves: normal 

Motor system:

 Tone:                    Right           Left

              UL          N                N

              LL.          N                N

Power:               Right.      Left

            UL.               5/5.            5/5

            LL.                5/5.             5/5

 Reflexes:               Right.                Left

B.                               ++.                  ++

T.                                 +.                   + 

S.                                ++                  ++

K.                                ++                  ++

A.                                 +.                   +

Babinski -   Negative 

Sensory system:

 2 point discrimination: 

UL.                             +                         +

LL                        Absent in toes 

Vibration: Medial malleolus.   4.8s    4.2s

                  Knee                       5.7.    5.3

                  Elbow.                     7.89. 8.1

Proprioception: 

UL                       +                                 +

LL   - Absent in Greater toe and second toe in both left and right LL 

Investigations:

15/3/22

S. Lipase: 48 IU/L

S. Amylase: 74 IU/L

Urine for ketone bodies: negative 

ABG: 

LFT: 

TB: 1.08

DB: 0.24

AST: 18

ALT: 10

Alk P: 242

TP: 7.3

Alb: 4

A/G: 1.23

Serum creatinine: 1.0

Serum urea: 15

Hemogram: 

Hb: 10.5

TLC: 5,400

N:65

L: 28

PLT: 2.30

 

Na: 138

K: 4.1

Cl: 99

Diagnosis: 

Uncontrolled sugars 

Diabetic ulcer on left lower limb 

Diabetic neuropathy

Treatment: 

1. Inj. HAI 6U given STAT

2. Inj. NS . 2 bolus given 

3. Inj. PANTOP 40mg IV OD

4. Tab. PREGABALIN 75mg OD H/S

5. Inj. TRAMADOL 1 amp in 100ml NS IV

6. Inj. ZOFER 4mg IV TID

7. Inj. THIAMINE 100mg + 100ml NS IV BD 

8. Tab. ULTRACET 1/2 PO/ QID 

9. Inj. HAI 10 units—x—6 units  pre meal and Inj. NPH 6 units BD

NEW ADMISSION 

16/3/22

AMC BED 1 

S: Complaints of pain in left lower rib region

O: 

Temperature: 98.6°F

BP: 130/100 mmHg

PR: 102 bpm 

GRBS: 144mg/dl

CVS: S1 S2 +, 

Not thrills or murmurs heard.

RS: BAE+, normal vesicular breath sounds heard 

CNS:

Motor system:

 Tone:   R.     L

UL.     N.      N 

LL.     N.      N 

Power:  R.     L

UL.       5/5.  5/5

LL.       5/5.  5/5

 Reflexes:    R.     L

B.               ++.     ++

T.                +.        + 

S.               ++     ++

K.               ++    ++

A.               +.     +

Babinski.   Negative 

Sensory system:

Sensory system:

 2 point discrimination: 

UL.    +.     +

LL    Absent in toes 

Vibration: 

Medial malleolus.4.8 4.2s

Knee                       5.7 5.3.                     Elbow.                    7.89. 8.1

Proprioception: 

UL   +.      +

LL.  Absent in Greater toe and second toe in both left and right LL 

P/A: soft, tenderness present in left hypochondrium. 

LFT: 

TB: 1.08

DB: 0.24

AlkP: 242

S. Lipase: 48

S. Amylase: 74

RBS: 370 mg/dl

UKB: Negative 

Blood urea: 15

Serum creatinine: 1.0

Na: 138

K: 4.1

Cl: 99

Hb: 10.8

TLC: 5,400

N: 65

Plt: 2.3 lakh

GRBS Charting: 

2AM (16/3/22): 101mg/dl

6AM (16/3/22): 97 mg/dl

8 AM ( 16/3/22): 144 mg/dl

A: Uncontrolled sugars 

Diabetic ulcer on left foot 

RTA with ?Left lower rib fracture

Diabetic neuropathy

P: 

1. Inj. PANTOP 40mg IV OD

2. Tab. PREGABALIN 75mg OD H/S

3. Inj. TRAMADOL 1 amp in 100ml NS IV

4. Inj. ZOFER 4mg IV TID

5. Inj. THIAMINE 100mg + 100ml NS IV BD 

6. Tab. ULTRACET 1/2 PO/ QID 

7. Inj. HAI 10 units—-x—-6 units TID pre meal and Inj. NPH 6 units BD

17/3/22

https://caseopinionsbyrollno156.blogspot.com/2022/03/36-year-old-with-pain-in-left-lower-rib.html

S: Complaints of pain in left lower rib region

O: 

Temperature: 98.6°F

BP: 130/100 mmHg

PR: 98 bpm 

GRBS: 305mg/dl

CVS: S1 S2 +

RS: BAE+

CNS:

Motor system:

 Tone:   R.     L

UL.     N.      N 

LL.     N.      N 

Power:  R.     L

UL.       5/5.  5/5

LL.       5/5.  5/5

 Reflexes:    R.     L

B.               ++.     ++

T.                +.        + 

S.               ++     ++

K.               ++    ++

A.               +.     +

Babinski.   Negative 

Sensory system:

Sensory system:

 2 point discrimination: 

UL.    +.     +

LL    Absent in toes 

Vibration: 

Medial malleolus.4.8 4.2s

Knee                       5.7 5.3.                     Elbow.                    7.89. 8.1

Proprioception: 

UL   +.      +

LL.  Absent in Greater toe and second toe in both left and right LL 

P/A: soft, tenderness present in left hypochondrium. 

FBS(16/3):107 mg/dl

PLBS(16/3): 383mg/dl

Total cholesterol: 217mg/dl

TAG: 438

HDL: 55

LDL: 122

A: Uncontrolled sugars 

Diabetic ulcer on left foot 

Diabetic neuropathy

RTA with left 11th rib displaced fracture 

P: 

1. Inj. PANTOP 40mg IV OD

2. Tab. PREGABALIN 75mg OD H/S

3. Inj. TRAMADOL 1 amp in 100ml NS IV

4. Inj. ZOFER 4mg IV TID

5. Inj. THIAMINE 100mg + 100ml NS IV BD 

6. Tab. ULTRACET 1/2 PO/ QID 

7. Tab. GLIMY M2 PO/BD