21M K/C/O DM 1 Since 2 Years ; Previous H/O Fulminant Hepatic Failure & CVA 1 Year Back

Previous Admission Blog : 


Present Admission :


DOA - 18/1/2023
Discharge Date : 20/01/23
Male Medical Ward
Unit:3

Case History and Clinical Findings
PATIENT CAME TO OPD WITH CHIEF COMPLAINTS OF :
WEIGHT LOSS WITHIN 1 MONTH FROM 73 KGS TOP 67 KGS
POLYDYPSIC SINCE 6 MONTHS .

HISTORY OF PRESENT ILLNESS:-
PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK THEN HE NOTICED GRADUALLOSS OF WEIGHT NEARLY 7 KGS ( UNINTENSIONAL - FROM 73 KGS TO 67 KGS) IN A SPANOF 1 MONTH.HE HAD H/O POLYDYPSIA SINCE 6 MONTHS(DRINKS 7 TO 8 LITERS OF WATERPER DAY).
H/0 POLYURIA,DELAYED WOUND HEALING PRESENT .TINGLING SENSATION OF FINGERSOF LOWER LIMBS.
NO H/O NUMBNESS OR LOSS OF SENSATION.NO H/O FATIGUE,GIDDINESS.
NO H/O FEVER,BURNING MICTURITION.
OPTHALMOLOGY REFERRAL WAS TAKEN ON 19/1/2023 I/V/O DIABETIC RETINOPATHY ,ADVISE FOLLOWED
ENDOCRINOLOGY REFERRAL WAS TAKEN ON 20/1/2023 I/V/O UNCONTROLLED SUGARSWITH MULTIPLE DAILY INSULIN , ADVISE FOLLOWED
PATIENT WAS TREATED ADEQUATELY WITH MEDICATION AND DISCHARGED INHEMODYNAMICALLY STABLE CONDITION

PAST HISTORY:-
K/C/O TYPE 1 DM SINCE 2 YEARS( ON INJ.HAI 40U INJ.NPH 40 U ).
H/O FULMINANT HEPATIC FAILURE A YEAR BACK AND H/O CVA 1 YR BACK .NOT A KNOWN CASE OF HTN,THYROID,TB,EPILEPSY,ASTHMA,CAD.

PERSONAL HISTORY:-DIET : MIXED
SLEEP AND APETTITE -NORMALBOWEL AND BLADDER- REGULARNO ADDICTIONS
NO KNOWN ALLERGIES

FAMILY HISTORY:-NOT SIGNIFICANT

GENERAL EXAMINATION:
PATIENT WAS EXAMINED AFTER TAKING HIS CONSENT
PATIENT IS CONSCIOUS , COHERENT , COOPERATIVE , WELL ORIENTED TO TIME , PLACEAND PERSON
HE IS MODERATELY BUILT AND NOURISHED
NO SIGNS OF PALLOR , ICTERUS , CYANOSIS , CLUBBING , OEDEMA , LYMPHADENOPATHY

HIS VITALS:
TEMPERATURE : AFEBRILEBP : 120/80 MM HG
PULSE RATE : 78 / MINRESP.RATE : 16 CPMGRBS:160 MG/DL

SYSTEMIC EXAMINATION:
CVS- S1 S2 HEARD,NO MURMURS PRESENT.
RS - BILATERAL AIR ENTRY PRESENT
NORMAL VESICULAR BREATH SOUNDS HEARDPER ABDOMEN : SOFT , NON TENDER
CNS :NO FOCAL NEUROLOGOCAL DEFICITS

Treatment Given(Enter only Generic Name)
INJ. HAI SC /TIDINJ NPH SC/TID
VITAL MONITORING 6 TH HRLYGRBSMONITORING7UNITPROFILE

Investigations (18/1/2023):
POST LUNCH BLOOD SUGAR-403 mg/dl
SERUM CREATININE -0.8 mg/dl
HBsAg-RAPID- Negative
Anti HCV Antibodies -Non Reactive
HIV 1&2 ELISA-Non Reactive

COMPLETE URINE EXAMINATION (CUE)
COLOUR -Pale yellow
APPEARANCE-Clear
REACTION-Acidic
SP.GRAVITY-1.010
ALBUMIN-Nil
SUGAR- Nil
BILE SALTS - Nil
BILE PIGMENTS -Nil
PUS CELLS-2-3
EPITHELIAL CELLS-2-3
RED BLOOD CELLS-Nil
CRYSTALS - Nil
CASTS - Nil
AMORPHOUS DEPOSITS - Absent 
OTHERS-Nil
SERUM ELECTROLYTES (Na, K, C l)
SODIUM-140 mmol/L
POTASSIUM -5.0 mmol/L
CHLORIDE -98 mmol/L

LIVER FUNCTION TEST (LFT)
Total Bilurubin- 0.88 mg/dl
Direct Bilurubin -0.17 mg/dl
SGOT(AST) -13 IU/L
SGPT(ALT) -12 IU/L
ALKALINEPHOSPHATASE -234 IU/L
TOTAL PROTEINS -7.0 gm/dl
ALBUMIN - 4.5 gm/dl
A/G RATIO -1.83

19-1-2023 05:11:AM
POST LUNCHBLOODSUGAR
19-1-2023 05:11:AM - 125 mg/dl

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