45M DM with Lateral Medullary Syndrome
Admission Date: 24/06/2023 03:30 PM
Discharge Date Date: 30/6/23
Name of Treating Faculty
DR. RAKESH BISWAS (HOD)
DR. SUSMITHA (SR)
DR. DEEPIKA (PGY2)
DR. NITHIN (PGY1)
Diagnosis
DIABETIC KETOSIS (RESOLVED) SECONDARY TO ACUTE GASTROENTERITIS (RESOLVED) WITH GIDDINESS SECONDARY TO LATERAL MEDULLARY SYNDROME WITH K/C/O DM SINCE 13 YRS , K/C/O HTN SINCE 1 MONTH
Case History and Clinical Findings
PATIENT CAME TO CASUALTY WITH C/O GIDDINESS ON AND OFF SINCE 5 DAYS. PT WAS APPARENTLY NORMAL 5 DAYS BACK AND THE HE STARTED HAVING GIDDINESS ON AND OFF , INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE.
C/O VOMITINGS (4 - 5 EPISODES , WATERY , NON PROJECTILE ,ILIOUS WITH FOOD PARTICLES AS CONTENTS AND WITH BLOOD TINGED . RELIEVED WITH MEDICATION C/O LOOSE STOOLS (4-5 EPISODES ,WATERY , NOT BLOOD STAINED, NON MUCOID , NON FOUL SMELLING )
C/O PAIN ON RIGHT SIDE OF BODY ALONG WITH WEAKNESS OF RIGHT LOWER LIMB 5 DAYS BACK AND RELIEVED
C/O FACILA PUFFINESS SINCE 5 DAYS , LOW ABCK ACHE SINCE 1 DAY
NO C/O FEVER , PAIN ABDOMEN , DECREASED URINE OUTPUT , PEDAL EDEMA PAST HISTORY
PATIENT VISITED LOCAL HOSPITAL 1 MONTH BACK WITH C/O HEADACHE, SWEATING, GIDDINESS AND WAS DIAGNOSED AS HYPERTENSIVE AND PUT ON MEDICATIONS. PATIENT IS A KNOWN CASE OF DM II SINCE 13 YEARS AND IS ON MEDICATION. NOW USING
GLIMI-M4 FORTE PO/OD(MORNING) AND GLIMI-M3 FORTE PO/OD(NIGHT)
Co Morbidities:
K/C/O HTN SINCE 1 WEEK
THE PATIENT WAS OPERATED FOR HAEMORRHOIDS 20 YEARS BACK NOT A KNOWN CASE OF CAD, BRONCHIAL ASTHMA, EPILEPSY, TB. PERSONAL HISTORY
DIET- MIXED
APPETITE- DECREASED SINCE 5 DAYS SLEEP- ADEQUATE
BOWEL AND BLADDER- REGULAR
ADDICTIONS- BINGE ALCOHOLIC SINCE 13 YEARS.STOPPED CONSUMPTION 6 YEARS BACK- HABITUATED TO SOFT DRINKS
CHEWING TOBACCO SINCE 20 YEARS. NO KNOWN ALLERGIES
FAMILY HISTORY
NO H/O DM IN THE FAMILY GENERAL EXAMINATION
PATIENT WAS EXAMINED IN A WELL LIT ROOM AFTER TAKING INFORMED CONSENT. HE IS CONSCIOUS, COHERENT AND COOPERATIVE; MODERATELY BUILT AND WELL NOURISHED.
NO ICTERUS, CLUBBING, CYANOSIS, LYMPHADENOPATHY, EDEMA.
VITALS ON 24/06/2023BLOOD PRESSURE:170/100 MMHGPULSE PRESSURE: 60 BPMRESPIRATORY RATE: 14CPMTEMPERATURE: AFERBILESPO2: 98% ON ROOM AIRGRBS:428MG/DL
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM : B/L AIR ENTRY PRESENT,NORMAL VESICULAR BREATH SOUND+
CARDIOVASCULAR SYSTEM:S1, S2 HEARD, NO MURMURS. 3.ABDOMINAL EXAMINATION: SOFT, NON- TENDER 4.CNS- NO FOCAL NEUROLOGICAL DEFICITS
Investigation
ON 24/06/23
HEMOGRAM HB 11.9 TC 8300 N/L/E/M/B 70/23/2/5/0 PCV 36 MCV 73.6 MCH 24.4 MCHC 33.1
RBC 4.87 PLT 3.49
ABG PH 7.45 PCO2 30.8 PO2 88.2 HCO3 21.1
SERUM ELRCTROLYTES NA+ 142 K+ 4.4 CL- 101 CA IONISED 1.19 SERUM CREATININE 1.0 MG/DL
BLOOD UREA 57 MG/DL RBS 423 MG/DL
CUE PALE YELLOW ,CLEAR ,ACIDIC SPECIFIC GRAVITY 1.010 PUS CELLS 3-4 URINE FOR KETONE BODIES POSITVE
SEROLOGY
HBSAG,HIV 1,2, ANTI HCV -NEGATIVE ON 25/06/23
HEMOGRAM HB 11.3 TC 11200N/L/E/M/B 77/16/1/6/0 PCV 33.7 MCV 74.1 MCH 24.8 MCHC 33.5
RBC 4.55 PLT 3.23
ABG PH 7.43 PC02 28.1 PO2 102 HCO3 18.6
SERUM ELRCTROLYTES NA+ 135 K+ 3.2 CL- 98 CA IONISED 1.13
FBS 81 MG/DL
LIPID PROFILE TOTAL CHOLESTEROL 174MG/DL HDL 47 TAG 197 LDL 126 VLDL 39.4 26/06/2023
SERUM ELECTROLYTES NA+ 139 K+ 3.5 CL- 103 CA IONISED 1.24 27/6/2023
HEMOGRAM HB 12 TC 7600 N/L/E/M/B 62/30/3/5/0 PCV 36.9 MCV 77.5 MCH 25.2 MCHC 32.6
RBC 4.76 PLT 2.79 28/06/23
HEMOGRAM HB 12.3 TLC 10300 N/L/E/M/B 55/36/2/7/0 PCV 37.8 MCV 78.5 MCH 25.5 RBC 4.81
PLT 3.12
29/6/23 HB 11.5 TLC 7200 PCV 35 MCV 78 MCH 25.4 MCHC 32.5RBC 4.53 PLT 2.59 URINE C/S: NO GROWTH
USG : GRADE 1 FATTY LIVER
MRI BRAIN PLAIN :ACUTE INFARCT IN LATERAL ASPECT OF MEDULLA ON RIGHT SIDE TO RULE OUT WALLENBERG/ LATERAL MEDULLARY SYNDROME
2D ECHO:
TRIVIAL TR/AR, NO MR NO RWMA
NO AS/MS
GOOD LV SYSTOLIC FUNCTION
NO DIASTOLIC DYSFUNCTION, NO PAH/PE
OPHTHALMOLOGY REFERRAL FOR FUNDOSCOPY I/V/O DIABETES SINCE 13 YRS :
RT EYE MILD, NON PROLIFERATIVE DIABETIC RETINOPATHY CHANGES NOTED
ADV: STRICT DIABETIC DIET, GLYCEMIC CONTROL, FUNDOSCOPIC EXAMINATION EVERY 6 MONTHS
ENT REFERRAL I/V/O VERTIGO :
ADV: RULE OUT CENTRAL PATHOLOGY FOR NYSTAGMUS, REVIEW WITH REPORTS
Treatment Given(Enter only Generic Name)
1.IVF NS @100 ML /HR X 7 DAYS
2.IVF 5D @50 ML/HR X1 DAY
3.INJ KCL 2 AMPOULES IN 500 ML NS IV OVER 5HRS X 1 DAY
4.INJ HUMAN ACTRAPID INSULIN INFUSION (1 ML+39 ML ) @6 ML/HR X 2 DAYS
5.INJ HUMAN ACTRAPID INSULIN S/C TID BEFORE MEALS ACCORDING TO GRBS X 5 DAYS
6.INJ NPH S/C BD BEFORE MEALS ACCORDING TO GRBS X5DAYS
7.INJ PAN 40 IV/BD X 7 DAYS
8.INJ BUSCOPAN IM/SOS X 6 DAYS
9.TAB TELMA 40 MG PO/OD X 7 DAYS
10.TAB PROMETHAZINE 25 MG PO/TID X 4 DAYS
11.TAB ECOSPRIN PO/HSX 3 DAYS
12.TAB SPOROLAC-DS PO /TIDX 3 DAYS
13.SYRUP POTCHLOR 15 ML PO/BD X 3 DAYS
Advice at Discharge
1.INJ HUMAN ACTRAPID INSULIN S/C TID BEFORE MEALS ACCORDING TO GRBS ( 14-14-12 )
2.INJ NPH S/C BD BEFORE MEALS ACCORDING TO GRBS ( 12- X- 10 )
3.TAB PAN 40 PO/OD X 5 DAYS
4.TAB TELMA 40 MG PO/OD
5.TAB PROMETHAZINE 25 MG PO/TID X 4 DAYS
6.TAB ECOSPRIN PO/HS
7.SYRUP POTCHLOR 15 ML PO/BD X 5 DAYS
8.TAB MVT PO/OD X 15 DAYS
