1801006039 - 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.

A 43 year old male from Suryapet, Daily wage worker by occupation came to hospital with

C/o Wound over the posterior aspect of right foot with foul smelling discharge since 6 months

History of Presenting Illness

Patient was apparently asymptomatic 6 months ago then he developed infection in heel crack insidiously which progressed gradually to the current wound size. Wound was taken care by regular dressing at a local hospital 

Patient developed  Right lower limb edema 2 weeks back which was insidious in onset and gradually progressed from ankle to knee

Patient developed fever 10 days back and subsided 3 days back which was associated with chills, body pains, cough and cold and 2 episodes of Vomiting for 3 days. Symptoms improved on taking medication.

1 day back foul smelling purulent discharge was found to be oozing out of the wound so patient came to hospital to get it treated. 

H/o polyuria, nocturia

No h/o polydipsia, polyphagia

No h/o burning micturition

No apparent h/o trauma to the right foot

Past History 

K/c/o Type 2 Diabetes Mellitus since 10 years and is on Metformin medication (1000 mg  morning and 500 mg night)

Not a k/c/o Hypertension, TB, Epilepsy, CVA, CAD, Asthma

H/o hemorrhoids surgery 10 years back

Personal history 

Patient is a daily wage worker lifting weights everyday as a part of his work

Appetite is decreased since 1 week

Diet is Mixed

Sleep is adequate 

Bowel movements are regular 

Polyuria and Nocturia present

Chronic alcoholic since 20 years 

Has been chewing Gutka for the past 20 years

General Physical Examination 

Patient is Conscious  and Co operative

Well oriented to time, place and person 

No Pallor, Icterus,  Clubbing,  Cyanosis,  Koilonychia, Generalised Lympadenopathy

Patient has Right lower limb below knee pitting type of edema. 

Local rise of temperature over the edematous limb

Vitals:

Temp: afebrile

PR: 96 bpm

RR: 20 /min

BP: 140/90 mm hg

GRBS- 550 mg/dl

Systemic Examination 

CVS: S1 S2 heard

Apex beat palpable in left 5th ICS

Respiratory system:

Non Vesicular Breath Sounds heard

Abdominal Examination 

Abdomen is scaphoid in shape and Umbilicus is inverted. Equal symmetrical movements in all quadrants with respiration and no visible peristalsis and pulsations over Abdomen

No Organomegaly, No tenderness

Bowel sounds heard

CNS:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES :Normal

SENSORY EXAMINATION

Spinothalamic sensation (Crude touch, Pain, Temperature) intact

Dorsal column sensation of fine touch and Proprioception intact

Vibration -  Decreased sensation in lower limbs

Cortical sensation ( Two point discrimination,  tactile localisation) intact.

MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee reflexes.

Ankle reflex on right side could not be elicited due to presence of ulcer

CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

Investigations 

On the day of admission  (15/03/2023)

RBS  is 419 mg/dL

Blood Urea is 49 mg/dL

CUE shows Acidic reaction with ++ Albumin and ++++ Sugars

Negative Serology findings for HBsAg, HIV 1/2 and Anti HCV antibodies 

Hemogram

Hb  10.7 gm/dL

Total count  17,300 cells/cumm

Neutrophils 8.8 %

Lymphocytes  07 %

PCV   31.1 vol%

RBC count  3.54 millions/cumm

Serum Creatinine   2 mg/dL

Serum electrolytes 

Sodium 128 mEq/L

Potassium 5.2 mEq/L

Urine positive for Ketone bodies 

ABG

pH  7.34

pCO2  22.7

pO2  35.9

On 16/03/2023

Sodium 132 mEq/L

Potassium 4.4 mEq/L

ABG

pH 7.39

pCO2 25.3

pO2 88

HbA1C 6.8

Chest X ray 

Electrocardiogram 

Diagnosis 

Diabetic Ketoacidosis withChronic non healing ulcer

 

Treatment plan

NBM

Inj. HAI 6U/IV/STAT

IV Fluids- NS

      1st hour- 1lit

      2nd hour-500ml

      3rd hour- 500ml

Then 250ml/hr till 24 hours

Inj. HAI infusion 1ml (40units) in 39ml NS at 6ml/hr 

On 16/3/23:

IV Fluid- FLUSODEX at 100ml/hr

Human Actrapid Insulin infusion at 3ml/hr

Inj. METROGYL 500mg IV/TID

Inj. PAN 40 mg PO/OD

Inj. THIAMINE 200mg in 100 ml NS BD

Strict output monitoring

GRBS monitoring hourly