Uncontrolled sugars in Alcoholic patient

 

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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan.

36 years old man who is a biochemistry professor by occupation came to the opd with chief complaints of pain in left lower rib region since 8-3-2022 and vomitings since 13-03-2022.

 

History of presenting illness:

Patient was apparently asymptomatic 7years back then he developed giddiness and fall so he went to local hospital there he was diagnosed as diabetic, from then he was on OHA(metformin) by taking OHA he was fine and his FBS,PLBS used to be control few years. later he shifted from GlimyM2 to Glimy mV1 2-3 months ago . And since 1 week he is not been under regular  medication. 

3years ago patient was on binge alcohol and didn't take food and had pain abdomen he went to hospital then he was diagnosed to have Acute pancreatitis and took treatment for 15 days at outside hospital.

3years ago he developed a corn and thickening on the planter aspect of left greater toe ,patient himself used to cut the thickened part,which 1year ago it turned into ulcer for which he under went wound debridement.He does his own dressing using spirit ,Iodine and cotton.

He stopped doing his job since 2 yrs and just stays at home and recently he has been teaching in a few colleges as guest lecturer.

2years ago he has a h/o Organophoshorus poisoning for which he was admittted to hospital and got treated.

1 1/2year ago again he started binge drinking and had pain abdomen but he was not diagnosed to have acute pancreatitis.

1year ago he had a complaints of burning sensation of feet,tingling sensation of both lower limb

On 8-3-2022  he has a h/o of fall from the bike and injured to lower rib,left side of hypochondriac region.

Since 1 week he is on binge alcohol drinking without taking any food and OHA.

He is having vomitings since 13-3-2022 with contains food,non bilious,non projectile.

He vomited what ever he consumed  even water

Past history:

No h/o hypertension, tuberculosis, asthma,epilepsy 

H/o diabetes since 7 years.

Family history:Not significant.

Personal history :

He is biochemistry professor,he goes to college for teaching carry on his daily activities normally.

He started consuming alcohol 10years ago and he got married and divorced after two year of marriage life after one year he got married again and divorced after 7years of marriage. 

Physiological habits:

Diet-Routine-Morning as breakfast- Rice with curry,

                      Afternoon as lunch-Rice with curry.

                      Evening around 5 pm- Java (glass)

                     Night  as  dinner - Roti

                     

Appetite-normal

Sleep-adequate 

Bowel and bladder movements-regular

Addictions-h/o taking alcohol from 10 years and binge alcohol in between.

General examination 

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

Moderately built and moderately nourished.

Pallor-absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent 

Pedal edema-present  upto ankle in left foot

7

Vitals:

Temperature-95.2F

Pulse rate-103bpm

Blood pressure-120/80mmHg

Respiratory rate:18cpm

SpO2-98%

Systemic examination:

CVS-S1S2 heard

RS-BAE+NVBS

P/A-soft,tenderness in the epigastric and left hypochondriac region.

CNS-NFND

Investigations:

GRBS-

15-3-22 : 382mg/dl

16/3/22,

              2am 101mg/dl

              6 am: 97 mg/dl

              8 am: 144 mg/dl

             8pm-260mg/dl

             10pm-390mg/dl

18/3/22

            8 am- 332 mg/dl

           10am- 259 mg/dl

             1 pm-251mg/dl

             3pm- 245mg/dl

     

  19-3-2022 

8:00am - 332 mg/dl

HAI - 6units and NPH-5units

10:00am - 259 mg /dl

1:00pm - 231 mg/dl

                       HAI-8 units 

3:00pm - 245 mg/dl

7:00pm - 245 mg/dl

20-3-22

Morning before food -400

Morning after food -250

Afternoon-2500

5 pm -182

10:30pm - 175

21-03-2022

8:00am   -271 mg/dl

10:00am -224mg/dl

12:30 pm -106mg/dl

Note: From 22 -03-2022 patient was on OHA ; that is on 

Glimy m3

From 26-03-2022 ,patient was on glimy m4 morning before food  ,glimy m3 night before food and metformin morning and night after food.

And on 29-03-2022 he is on glimy m4  and metformin 

From 26-03 -2022 patient is advised to have idly in morning, rice at afternoon and Roti at night which was he routine diet previously

15/3/22

S. Lipase: 48 IU/L

S. Amylase: 74 IU/L

Urine for ketone bodies: negative 

LFT: 

TB: 1.08

DB: 0.24

AST: 18

ALT: 10

Alk P: 242

TP: 7.3

Alb: 4

A/G: 1.23

ABG: 

USG ABD

CT scan - abdomen and pelvis

Chest X ray

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 ⁹

8. Tab. ULTRACET 1/2 PO/ QID 

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

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

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

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