57M Uncontrolled DM2 ; CKD

 Case History and Clinical Findings

C/O 1 EPISODE OF LOC ON 18/2/23 AFTERNOON AROUND 12 PM

HOPI:

PT WAS APPARENTLY NORMAL UNTIL AFTERNOON (18/2/23) THEN HE SUDDENLY HAD 1 EPISODE OF LOSS OF CONSCIOUSNESS FOR PERIOD OF 2 MINUTES AND THEN REGAINED CONCIOUSNESS.

NO H/O NAUSEA,VOMITINGS,HEADACHE,TRAUMA,ENT BLEED, DIMMING OF VISION.

NO H/O CONFUSION,SEIZURES,CHEST PAIN,SOB

NO H/O INVOLUNTARY BOWEL AND BLADDER PASSAGE,TONGUE BITE

PAST HISTORY:

K/C/O TYPE 2 DM SINCE 20 YEARS (ON T.GLIMI M1 PO/OD)

K/C/O HYPERTENSION SINCE 20 YEARS(ON T.MET-XL 50 MG PO/OD AND T.TELMA 40 MG PO/OD)

PT.SON GIVES H/O STOPPING MEDICATION FOR AROUND 20-30 DAYS 2 YEARS BACK

K/C/O CKD SINCE 2 YEARS ON CONSERVATIVE MANAGEMENT

N/K/C/O CAD,CVA,TB,EPILEPSY,ASTHMA,THYROID DISORDERS

ON EXAMINATION:

PT IS C/C/C

TEMP:97 F

PR:74 BPM

BP:170/100 MM HG

RR-18 CPM

RS: BAE +

NORMAL VESICULAR BREATH SOUNDS.

CREPTS HEARD IN RIGHT IAA

CVS: S1S2+,NO MURMURS

P/A: SOFT,NON TENDER

CNS: HMF-INTACT

NO FOCAL NEUROLOGICAL DEFICIT


Provisional Diagnosis:-

UNCONTROLLED DM 2 WITH CKD SECONDARY TO DIABETIC NEPHROPATHY

K/C/O DM, HTN SINCE 20 YEARS

K/C/O CKD SINCE 2 YEARS(ON CONSERVATIVE MANAGEMENT)


Investigation:-

HEMOGRAM-

HB-10.3

HB-10.3

TLC-10,100

PCV-29.7

PLATELET-3.30 LAKH

RBS- 615 MG/DL

URINE FOR KETONE BODIES-NEGATIVE

ECG- TALL T WAVE SUGGESTIVE OF HYPERKALEMIA.

USG ABDOMEN-

B/L GRADE 2 RPD CHANGES

RT.KIDNEY-8*3.6 CM

LT.KIDNEY-8.5*3.8 CM

URINARY BLADDER- PARTIALLY DISTENDED

LIVER AND PANCREAS- NORMAL


Treatment Given:-

FLUID RESTRICTION<1.5 LIT/DAY

INJ.LASIX 20 MG IV/BD

INJ.HAI S/C / TID /ACCORDING TO GRBS

INJ.ERYTHROPOEITIN 5000 IU WEEKLY ONCE

TAB.NICARDIA 10MG PO/BD

TAB.NODOSIS 500 MG PO/BD

TAB.OROFER XT PO/OD

TAB.SHELCAL 500 MG PO/OD

TAB.BIO-D3 PO/OD

NEBULISATION WITH 2 RESPULES SALBUTAMOL

MONITOR VITALS


LAMA NOTES:

PATIENT AND HIS ATTENDERS HAVE BEEN EXPLAINED ABOUT PATEINT CONDITION,RISKS INVOLVED WITH IT AND NEED FOR THEM TO STAY AND NEED FOR DIALYSIS IN THEIR OWN UNDERSTANDABLE LANGUAGE.BUT PATIENT AND HIS ATTENDERS DENIED THE ADVICE AND WANT TO LEAVE AGAINST MEDICAL ADVICE.

HOSPITAL STAFF AND DOCTORS HERE ARE NOT REPONSIBLE FOR ANY FURTHER DETERIORATION OF PATIENT CONDITION.

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