37M Uncontrolled DM ; Sepsis ; Lt.LL Cellulitis
1st Admission :
Case History and Clinical Findings
A 35 YR OLD MALE WHO WAS ATRUCK DRIVER BY OCCUPATION WAS BROUGHT TO THE CASUALITY WITH C/O ALTERED SENSORIUM AND
GENERALISED WEAKNESS SINCE 1WEEK
HOPI-
PT. WAS APPARENTLY ASYMPTOMATIC 10YRS AGO THEN HE DEVELOPED COUGH AND GENERALISED WEAKNESS FOR WHICH HE WENT TO HOSPITAL AND DIAGNOSED WITH DM AND WAS PRESCRIBED OHAS SINCE THEN HE STARTED USING OHAS BUT WAS ON IRREGULAR MEDICATION AND HAD POOR CONTROL OF SUGARS .THEN WAS ON INSULIN SINCE 7YS,STOPPED USING INSULIN FROM 15DAYS
2 YRS BACK HE DEVELOPED BOTH LL SWELLING WHICH GRADUALLY PROGRESSED TO ANASARCA SINCE THEN HE HAD FREQUENT ATTACKS OF HYPOGLYCEMIA AND DECREASED URINE OUTPUT
3 MONTHS BACK.PT.DEVELOPED FEVER WITH ULCER OVER RIGHT GREAT TOE. LOWER LIMB AND FACIAL PUFFINESS AGGRAVATED ,BROUGHT TO OUR HOSPITAL AND WAS ADMITTED AND DISCHARGED
SINCE 7DAYS,PT. HAD GENERALISED WEAKNESS , ALTERED BEHAVIOUR ,INCREASED SLEEPINESS DURING DAY TIME,ALTERED SLEEP CYCLE SINCE 1WEEK, AND WAS BROUGHT TO OUR HOSPITAL
PAST HISTORY-
K/C/O DM SINCE 10YRS AND ON INSULIN
DIAGNOSED WITH DM 10YRS BACK AND WAS PRESCRIBED OHAS SINCE THEN HE STARTED USING OHAS BUT WAS ON IRREGULAR MEDICATION AND HAD POOR CONTROL OF SUGARS .THEN WAS ON INSULIN SINCE 7YS.STOPPED USING FROM 15DAYS
K/C/O HTN SINCE 2YRS AND ON REGULAR MEDICATION
NOT A K/C/O TB/CAD/EPILEPSY/ASTHMA
PERSONAL HISTORY-
MIXED DIET
APPETITE DECREASED
BOWEL AND BLADDER HABITS -REGULAR
ADDICTIONS-CHRONIC ALCOHOLIC AND TAKES DAILY 90-180ML FOR ABOUT 10YRS AND STOPPED 2 YRS BACK
NO ALLERGIES
GENERAL EXAMINATION: AT PRESENTATION
PT. IS DROWSY/COHERENT/COOPERATIVE
PALLOR PRESENT
B/L PEDAL EDEMA PRESENT
NO ICTERUS, CYNOSIS, CLUBBING, LYMPHEDENOPATHY
TEMP- 98F
PR-98BPM
BP- 150/100MMHGSPO2-98% @ RAGRBS-HIGH
CVS- S1S2+,NO MURMURSRS-
R/s:- BAE+,NVBS HEARD
P/A- SOFT,NON TENDER,BOWEL SOUNDS+
CNS- ORIENTED TO TIME,PLACE AND PERSON
LEVEL OF CONSCIOUSNESS- DROWSY/AROUSABLE
SPEECH-SLURRED
NO SIGNS OF MENINGEAL IRRITATION
CRANIAL NERVES INTACT
NO SENSORY ABNORMALITY DETECTED
GCS 15/15
B/L PUPILS NORMAL IN SIZE AND REACTIVE TO LIGHT
AT THE TIME OF DISCHARGE:
PT. IS CONSCIOUS/COHERENT/COOPERATIVE
COURSE IN THE HOSPITAL:-
35 YEAR OLD MALE ADMITTED IN THE HOSPITAL WITH ABOVE MENTIONED COMPLAINTSNECESSARY INVESTIGATIONS WERE DONE ,
CONSERVATIVELY MANAGED
3 UNITS PRBC TRANSFUSIONS DONE ON[18/2/23,19/2/23,21/2/23]SYMPTOMS SUBSIDEDPATIENT HEMODYNAMICALLY STABLE AND PLANNED FOR DISCHARGE
GENERAL SURGERY OPINION TAKEN I/V/O DIABETIC FOOT
ADVICED ARTERIOVENOUS DOPPLER OF RT. LOWER LIMB,C/S OF DIABETIC FOOT SWAB
ARTERIOVENOUS DOPPLER OF RIGHT LOWER LIMB:
1.PROXIMAL PTA AND DPA SHOW BIPHASIC WAVIFORM,REST OF ARTERIES SHOW TRIPHASIC WAVIFORM
2.ALL EXAMINED VEINS SHOW NORMAL COLOUR UPTAKE WAVIFORM,RESPIRATORY PHASICITY
DIABETIC FOOT ULCER SWAB C/S:
FEW EPITHELIAL CELLS,FEW DISINTEGRATED PUS CELLS,MODERATE NUMBER OF GRAM NEGATIVE BACILLI,PLENTY OF GRAM POSITIVE BUDDING YEAST CELLS SEEN.
KLEBSIELLA PNEUMONIA ISOLATED
SENSITIVE TO GENTAMICIN,COTRIMOXAZOLE,AMIKACIN,MEROPENEM
RESISTANT TO AMOYCLAV,CEFUROXIME,CEFTAZIDIME,CEFEPIME
OPHTHALMOLOGY OPINION TAKEN I/V/O ANY DM AND HTN RETINOPATHIC CHANGES
ADVICE : FUNDOSCOPY DONE -NO RAISED ICT ,NO CHANGES OF HTN AND DIABETIC RETINOPATHY CHANGES
NEPHROLOGY OPONION TAKEN I/V/O SR.UREA-108MG/DL AND S.CREA-3.1MG/DL
ADVICED TAB.TELMA 40MG PO/OD
INJ.LASIX 20MG IV/BD
INJ.MEROPENEM 1GM IV/TID
INJ.INSILIN ACCORDINGLY EVERY 4TH HRLY
ENDOCRINOLOGY OPINION TAKEN I/V/O
Provisional Diagnosis:-
UNCONTROLLED SUGAR SECONDARY TO SEPSIS
SEPTIC ENCEPHALOPATHY (RESOLVED)
WET GANGRENE OF RIGHT GREAT TOE(RAYS AMPUTATION DONE)
ACUTE RENAL FAILURE ON CHRONIC KIDNEY DISEASE(DIABETIC NEPHROPATHY SINCE 2 YRS)
ANEMIA OF SHRONIC KIDNEY DISEASE
THROMBOCYTOPENIA (RESOLVED)
H/O DIABETES MELLITUS SINCE 10YRS
H/O HYPERTENSION SINCE 2YRS
Investigation:-
PT-15SECS
APTT-31SECS
INR-1.11
ECG-NORMAL SINUS PATTERN
2D ECHO:-
MILD TO MODERATE TR+ WITH PAH, MILD MR+,TRIVIAL AR+
NO RWMA,NO AS/MS,CONCENTRIC LVH+
GOOD LV SYSTOLIC FUNCTION
NO DIASTOLIC DISFUNCTION
EF-56%
BGT-A POSITIVE
HEMOGRAM;
HB. , TLC PLC
GM/DL CELLS/CUMM
17/02/23 6.0 21,600 95,000
19/02/23 5.8 15,400 42,000
20/02/23 6.5 13,500 46,000
21/02/23 6.3 11,000 33,000
22/02/23 8.2 14,000 96,000
23/2/23 7.1 9000 1,OO,200
USG ABDOMEN:
MODERATE ASCITIS
LEFT MILD PLEURAL EFFUSION
C/S OF URINE:
NO GROWTH SEEN
C/S OF BLOOD:
SKIN COMMENSALS GROWN
24 HRS URINARY PROTEIN -654MG/DAY
24HRS URINARY CREATININE -2.89G/DAY
Treatment Given:
NBM TILL FURTHER ORDERSIVF -NS@ 50ML /HRINJ.NAHCO3NBM TILL FURTHER ORDERSIVF -NS@ 50ML IV STATINJ.NAHCO3 50MEQ/L F/B 50MEQ/LINJ. HAI 6U IV STAT F/B ACCODING TO GRBS
INJ.PIPTAZ 4.5G IV STAT F/B 2.25GIV TID
INJ.CLINDAMYCIN 600MG IV / TIDSTRICT I/O CHARTINGGRBS MONITORING HOURlY
21/2/23:
DATE TIME GRBS INSULIN GIVEN
21/02/23 8AM 101 4U HAI+4U NPH
2PM 127 6U HAI
8PM 176 8U HAI
22/02/23 8AM 201 6U HAI+4 U NPH
2PM 100 6U HAI
8PM 79 4U HAI
23/02/23 8AM 198 6U HAI+4U NPH
12PM 100 6U HAI
8PM 92 4U HAI
Advice at Discharge:-
STRICT DIABETIC DIET
INJ.MIXTARD /SC
12U -----0-----8U
INJ.ERYTHROPOITIN 400UNITS/SC/TWICE WEEKLY
TAB.LASIX 40MG PO/BD
TAB.NICARDIA 10MG PO/TID
TAB.BACTRAM DS PO/BD X 5DAYS
TAB.CHYMEROL FORTE PO/TID
TAB.NODOSIS 500MG PO/OD
TAB.SERAX FORTE 20MG PO/TID
FLUID RESTRICTION <1.5 LITS/DAY
SALT RESTRICTION <2GM/DAY
RIGHT LOWE LIMB ELEVATION
REGULAR DRESSINGS
ACTIVE AMBULATION
2nd Admission :
Case History and Clinical Findings
CHIEF COMPLAINTS
37 YEAR OLD MALE PRESENTED TO CASUALITY WITH SOB SINCE 19/5/2023 MORNING 10:00AM
HOPI:-
PATIENT WAS APPARENTLY ASYMPTOMATIC 4DAYS BACK AND AFTER FRESEHEN UP HE DRANK RAGIJAVA AND TOOK MEDICATION PRESCRIBED BY US DURING DISCHARGE THEN HE SUDDENLY STARTED HAVING SOB GRADE 4
PAST ILLNESS
F/U/C/O SEPSIS SECONDARY TO LEFT LOWERLIMB CELLULITIS (RESOLVED) HFMEF (EF 48%) WITH AKI ON CKD WITH ANEMIA (NC/NC) SECONDARY TO ?CKD WITH THROMBOCYTOPENIA WITHN K/C/O DM2 SINCE 12 YEARS AND K/C/O HTN SINCE 2 YEARS
S/P RAYS AMPUTATION OF GREAT TOE
S/P FASCIOTOMY LEFT FOOT 13/5/2023
3 SESSION OF HAEMODIALYSIS WERE DONE
PERSONAL HISTORY:
DIET-MIXED
APPETITE -NORMAL
BOWEL AND BLADDER - REGULAR
SLEEP-ADEQUATE
ADDICTIONS- NO
ALLERGIES- NONE
FAMILY HISTORY:
INSIGNIFICANT
GENERAL EXAMINATION:
PATIENT IS CONSIOUS ,COHERENT ,COPERATIVE
NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY
VITALS:
TEMP-97.9F
BP- 120/80MMHG
PR-104BPM
RR-28CPM
SPO2-98% AT ROOM AIR
GRBS-580
SYSTEMIC EXAMINATION:
CVS-S1 S2 HEARD NO MURMURS
RS-BAE+ NVBS
P/A -SOFT NON TENDER,NO GUARDING,NO RIGIDITY, HERNIAL ORIFICES NORMAL
COURSE AT THE HOSPITAL:
PATEINT WAS ADMITTED I/V/O SOB GRADE 3 -4 INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE AND ON FURTHER EVALUATION,WAS FOUND TO HAVE HIGH SUGARS WITH GRBS 580 (URINE FOR KETONE BODIES- NEGETIVE) DUE TO NON COMPLIANCE TO MEDICATION WITH ABG SHOWING SEVERE METABOLIC ACIDOSIS ,INJ.NAHCO3 50MEQ IV STAT F/B 50MEQ IN 100ML NS. INJ.HAI 6U IV STAT GIVEN INFUSION 6ML/HR .INSULIN INFUSION GIVEN ACCORDING TO ALGORITHM 1 FOR 1 DAY LATER SHIFTED TO S/C INSULIN ACCORDING TO THE REQUIREMENT .TLC COUNT ELEVATED AND WAS STARTED ON INJ.PIPTAZ AND INJ METROGYL .SURGERY REFERAL WAS DONE ON 19/5/23 I/V/O LEFT LOWER LIMB S/P FASCIOTOMY ,SKIN OVER THE LEFT LIMB EDEMATOUS AND SHINY ERYTHEMA +,LOACL RISE OF TEMP+ EXTENDING TILL MID THIGH TO FOOT AND FASCIOTOMY INCISION PRESENT OVER MID THIGH,GRANULATION TISSUE PRESENT ,MINIMAL SLOUGH +,SEROUS DISCHARGE PRESENT FROM FASCIOTOMY SITE AND ADVICE FOLLWED AS PER ORDERDS AND REGULAR DRESSINGS WITH MGSO4 +GLYCERINE DRESSING DONE
ON DAY 2 PATEINT HAS LOOSE STOOLS (? ANTIBIOTICS INDUCED DIARRHEA AND ANTIBIOTICS STOPPED)
ON DAY3 ANTIBIOTICS STOPPED AND MANAGED CONSERVATIVELY ON 21/5/23 .PATIENT HAS BEEN TAKEN TO DIALYSIS 1ST SESSION WITH 2FFPS AND 1PRBC TRANSFUSION,(? UREMIC ENCEPHALOPATHY AND ANURIA)
PREVIOUS H/O SEPSIS SECONDARY TO LEFT LOWER LIMB CELLULITIS WITH HEART FAILURE WITH PRESERVED EJECTION FRACTION WITH AKI ON CKD WITH ANEMIA (NC/NC) WITH THROMBOCYTOPENIA
PATIENT WAS DISCHARGED WITH VITALS
TEMP-98.5
BP-140/70
PR 100BPM
RR-16CPM
SPO2-98%
GRBS -201 AT 8:00AM
PATIENT IS ADVISED FOR FOLLOWING I/V /O MAINTAINANCE OF HEMODIALYSIS
Provisional Diagnosis:-
UNCONTROLLED SUGEARS (? DIABETIC ACIDOSIS) LEFT LOWER LIMB CELLULITIS (RESOLVING) HEART FAILURE WITH PRESERVED EJECTION FRACTION WITH AKA ON CKD WITH ANEMIA (NC/NC) SECONDARY TO ? CKD WITH THROMBOCYTOPENIA 1 SESSION OF HEMODIALYSIS (2 FFPS AND 1 PRBC TRANSFUSION ) WITH K/C/O DM2SINCE 12 YEARS AND K/C/O HTN SINCE 2 YEARS
S/P RAYS AMPUTATION OF GREAT TOE
S/P FASCIOTOMY LEFT FOOT 13/5/2023
