A 67 yr old male came with complaints of vomitings since 10 days.
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Chief complaints:-
67 yr old male who is resident of choutuppal and saree weaver by occupation came to casuality with complaints of vomitings since 10 days.
History of present illness:-
Patient was apparently asymptomatic 10days back then he had vomitings which is sudden in onset and he pukes out whatever he eats after 5 mins which is non projectile . Contents of vomiting are food particles and non bilious .
He visited to other hospital and took medication but vomitings are not reduced .
There is h/o facial puffiness 7 days back before coming to hospital and he is unable to open is eyes because of facial puffiness.It is sudden in onset and gradually progressive which is more around the eyes. Puffiness reduced on medication.
H/O neck pain from 2 days and unable to move his head side to side due to pain .
H/O decreased urine output.
No h/o altered sensorium, giddiness .
No h/o abdominal pain, loin pain.
No h/o diarrhoea and constipation, dysphagia.
No h/o cough ,fever ,heamatemesis.
Past history:-
No similar complaints in the past .
He is known case of diabetic since 15 yrs .
There is h/o diabetic ulcer and amputated leg 4 yrs back .
H/o hypertension since 10 yrs .
Not known case of asthma ,TB ,CAD ,epilepsy, thyroid disorders.
Personal history:-
Diet - vegetarian
Sleep - adequate
Appetite- Normal
Bowel and bladder - Not passing motion and decreased urine output present
No h/o addictions and allergies.
Family history:-
His wife is also diabetic .
There is no other family history.
Treatment history:-
He is on regular diabetic medication and anti hypertensive medication.
After amputation of leg from 4 yrs he is on insulin.
General examination:-
Pt is conscious ,coherent and cooperative and moderately built and not nourished well.
Pallor present -
No- icterus,cyanosis,clubbing,lymphadenopathy.
Vitals:-
Temp- afebrile
PR- 69/ min
RR- 22 cpm
BP- 110/80 mm hg
Examination of oral cavity:-
No dental caries,hypertrophied gums
There is no proper oral hygiene and tongue is oedematous he is unable to talk because of it.
Abdominal examination:-
Inspection-
Shape of abdomen normal .
Umbilicus is inverted and normal.
All quadrants are equally moving with respiration.
No visible pulsations ,scars and sinuses.
No visible gastric peristalsis.
Skin over the abdomen is normal and no stretch marks seen.
No dilated veins .
Palpation:-
Inspectory findings are confirmed.
No local raise of temperature and no tenderness .
No hepatomegaly and splenomegaly on palpation.
Percussion:-
On percussion of liver dull note is heard from 5 th intercostal space to right costal margin.
Liver span is 6 cm .
Auscultation:-
Bowel sounds are heard.
Examination of other systems:-
CVS-
S1S2 heard , no added murmurs.
RS-
Normal vesicular breath sounds are heard.
Nervous system-
is intact
No altered sensorium, able to recognise people .
Investigatons:-
Also decrease in sodium levels and chloride levels also .
Albumin is positive in urine analysis
USG-
Provisional diagnosis:-
Hypoglycemia secondary to insulin with diabetic nephropathy with hyponatremia.
Treatment:-
On 16/03/22
-GRBS charting 2nd hrly
-inj ZOFER 4mg / iv / tid
- inj PAN 40 mg iv /BD
- IVF - 30 ml / hr
- Tab . LASIX 40 mg bd
- Tab. SHELCAL po / OD
_ inj. ERYTHROPOIETIN 4000 IU /SC weekly once .
On 17 / 03/22
Pt is conscious coherent and cooperative.
Cvs - S1S2 heard
RS- BAE present ,NVBS
PA - soft and non tender .
* Na+ increased from 111 to 115 mmmol/l
Rx -
- GRBS charting 6th hrly
-inj ZOFER 4mg / iv / tid
- inj PAN 40 mg iv /BD
- IVF - 30 ml / hr
- Tab . LASIX 40 mg bd
- Tab. SHELCAL po / OD
_ inj. ERYTHROPOIETIN 4000 IU /SC weekly once .
- 3%Nacl 15 ml / hr is given.
On 18/03/22
Pt is conscious coherent and cooperative.
Cvs - S1S2 heard
RS- BAE present ,NVBS
PA - soft and non tender.
Rx -
- GRBS charting 6th hrly
-inj ZOFER 4mg / iv / tid
- inj PAN 40 mg iv /BD
- IVF - 30 ml / hr
- Tab . LASIX 40 mg bd
- Tab. SHELCAL po / OD
_ inj. ERYTHROPOIETIN 4000 IU /SC weekly once .
- 3%Nacl 15 ml / hr is given.
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