80M Peripheral Neuropathy ; DM ; CKD ; BPH


http://23bonthadivya.blogspot.com/2024/05/camp-case-80-yr-old-male-cheif.html




1st Admission : 


Case History and Clinical Findings

C/O GIDDINESS SINCE 15 DAYS

HOPI-

PATIENT WS APPARENTLY ASYMPTOMATIC 15DAYS AGO THEN DEVELOPED EPISODES OF GIDDINESS A/W BLURRING OF VISION A/W SWEATING RELIEVED AFTER TAKING FOOD DAILY ONE EPISODE

H/O CHEST PAIN SINCE 4DAYS PRICKING TYPE ON AND OFF ,NO PRECIPITATING FACTORS

H/O TINGLING AND NUMBNESS OF LOWER LIMBS SINCE 10 YEARS EXTENDING FROM TIP OF TOES TO SHIN OF TIBIA

H/O BURNING SENSATION OF FEET SINCE 5 YEARS

H/O LOOSE STOOLS FOR 1 DAY WHICH WAS ONE WEEK AGO AND SUBSIDED ON MEDICATION FOLLOWED BY PAIN ABDOMEN IN UMBLICAL REGION SINCE THEN

NO H/O LOSS OF APPETITE SINCE 1 WEEK

NO H/O POLYURIA,POLYDIPSIA

NO H/O PALPITATIONS ,SOB

NO H/O HYPOGLYCEMIC EVENT AT NIGHT


NO H/O DECREASED URINE OUTPUT ,BURNING MICTURITION

NO H/O FEVER, PEDAL EDEMA ,FACIAL PUFFINESS

PAST H/O-

K/C/O HTN SINCE 30YRS AND ON T.TELMA AM 40/5

K/C/O DM SINCE 30 YRS ON INJ MIXTARD 20U(BBF)-X-15U(BBF)

K/C/O CKD SINCE 13 YEARS

ON EXAMINATION

PT IS CONSCIOUS, COHERENT,COOPERATIVE

TEMP-AFEBRILE

PULSE RATE 80 BPM

BP 110/80 MMHG

CVS-S1 S2 HEARD NO MURMURS

RS- BAE PRESENT NVB

P/A-SOFT,NON TENDER

OPHTHALMOLOGY REFERRAL I/V/O -DIABETIC RETINOPATHY

IMPRESSION -NORMAL FUNDUS STUDY


PROVISIONAL DIAGNOSIS :-

PERIPHERAL NEUROPATHY (SENSORY &MOTOR)

DIABETES MELLITUS SINCE 30 YEARS

HYPERTENSION SINCE 30 YEARS

CHRONIC KIDNEY DISEASE SINCE 13 YEARS

BENIGN PROSTATIC HYPERPLASIA


Investigation:-

RFT 04-05-2024 04:15:PM :-

UREA37 mg/dl50-17 mg/dl

CREATININE2.6 mg/dl1.3-0.8 mg/dl

URIC ACID6.7 mmol/L7.2-3.5 mmol/L

CALCIUM10.0 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS2.7 mg/dl4.5-2.5 mg/dl

SODIUM137 mmol/L145-136 mmol/L

POTASSIUM4.6 mmol/L.5.1-3.5 mmol/L.

CHLORIDE102 mmol/L98-107 mmol/L

LIVER FUNCTION TEST (LFT) 04-05-2024 04:15:PM :-

Total Bilurubin0.56 mg/dl1-0 mg/dl

Direct Bilurubin0.20 mg/dl0.2-0.0 mg/dl

SGOT(AST)12 IU/L35-0 IU/L

SGPT(ALT)10 IU/L45-0 IU/L

ALKALINE PHOSPHATASE179 IU/L119-56 IU/L

TOTAL PROTEINS6.9 gm/dl8.3-6.4 gm/dl

ALBUMIN4.0 gm/dl4.6-3.2 gm/dl

A/G RATIO1.42

HBsAg-RAPID04-05-2024 04:15:PM:-Negative 

Anti HCV Antibodies - RAPID04-05-2024 04:15:PM :-Non Reactive 

COMPLETE URINE EXAMINATION (CUE) 04-05-2024 04:15:PM:- 

COLOUR:-Paleyellow

APPEARANCEClear

REACTIONAcidic

SP.GRAVITY1.010

ALBUMIN-Nil

SUGAR+++

BILE SALTS-Nil

BILE PIGMENTS-Nil

PUS CELLS-2-3

EPITHELIAL CELLS-2-3

RED BLOOD CELLSNil

CRYSTALS-Nil

CASTS-Nil

AMORPHOUS DEPOSITS-Absent

OTHERS-Nil

POST LUNCH BLOOD SUGAR04-05-2024 04:17:PM:- 196 mg/dl140-0 mg/dl

ABG 05-05-2024 09:12:AM:- 

PH7.33

PCO229.7

PO290.0

HCO315.3

St.HCO317.2

BEB-9.1

BEecf-9.4TCO231.7

O2 Sat96.1

O2 Count15.5

HEMOGRAM:-

HB-11.1

TLC-6700

PLT-2.80

RBC-3.55

HBA1C-7.1 %

FBS-70 MG/DL

PLBS-196MG/DL

SPOT UPCR-

SPOT URINE PROTEIN -6.0

SPOT URINE CREATININE 87.5

RATIO 0.06

2DECHO-

EF-65 %

IVC-0.7CM COLLAPSING

TRIVIAL TR+/AR+ ,NO MR

NO RWMA ,NO AS/MS SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

GRADE 1 DIASTOLIC DYSFUNTION ,NO PAH/PE/LV CLOT

USG ABDOMEN &PELVIS (06/5/24)

IMPRSSION -B/L GRADE 1 RPD CHAGES IN KIDNEY

B/L RENAL CORTICAL CYSTS

GRADE 1 PROSTATOMEGALY


Treatment Given:-

T.TELMA -AM 40/5 PO/OD

T.DYTOR PLUS 10/25 PO/OD

T.PREGABALIN 75MG PO/HS

T.ECOSPORIN AV 75/10 PO HS

T.PAN 40MG PO/OD

INJ HAI S/C TID ACC TO GRBS

T.SHELCAL -XT PO/OD

TAB.NODOSIS 500MG PO/OD


2nd Admission : 


Case History and Clinical Findings

CHIEF COMPLAINTS :

DIFICULTY IN BREATHING SINCE 2 MONTHS, HARD STOOLS SINCE 1MONTH , BLOATING OF ABDOMEN SINCE 1MONTH , GIDDINESS SINCE 1 WEEK

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS BACK THEN HE DEVELOPED DIFFICULTY IN BREATHING WHICH IS OF GRADE 2 WITH NO AGGREVATING AND RELEIVING FACTORS

COMPLAINTS OF HARD PELLET STOOLS WITHOUT ANY BLOOD TINGE SINCE 1 MONTH

C/O BLOATING OF ABDOMEN SINCE 1 MONTH

N/H/O CHEST TIGHTNESS

N/H/O ORTHOPNEA PND

N/H/O BLEEDING MANIFESTATIONS

PAST HISTORY :

K/C/O HYPERTENSIOPN ON TAB.CINOD 10 MG BD SINCE 10 YEARS

K/C/O DM SINCE 30 YEARS ON INJ.HAI 8-10-8

K/C/O CKD SINCE 13 YEARS ON NODOSIS 500 MG


PERSONAL HISTORY:

DIET: MIXED

APPETITE: NORMAL

BOWEL AND BLADDER MOVEMENTS: REGULAR.

NO KNOWN ALLERGIES AND ADDICTIONS.

FAMILY HISTORY: NOT SIGNIFICANT.

GENEREAL EXAMINATION:

PATIENT IS C/C/C

TEMP: AFEBRILE

PR: 80 BPM

RR: 20 CPM

BP: 110/70 MMHG

SPO2: 98 @ RA.

SYSTEMIC EXAMINATION:

CVS: S1 S2 HEARD. NO MURMURS

RESPIRATORY SYSTEM: BAE+

P/A- SOFT, NON TENDER.

CNS- NO FOCAL NEUROLOGICAL DEFECTS.

OPTHALMOLOGY REFERRAL ON 20/5/24 I/V/O FUNDOSCOPIC EXAMINATION.

NO EVIDENCE OF DIABETIC OR HYPERTEMDOVE RETINOPATHY CHANGES.

COURSE IN HOSPITAL:

A 75 YEAR OLD MALE CAME WITHDIFICULTY IN BREATHING SINCE 2 MONTHS, HARD STOOLS SINCE 1MONTH , BLOATING OF ABDOMEN SINCE 1MONTH , GIDDINESS SINCE 1 WEEK.

PATIENT WAS DIAGNOSED AS ACUTE GASTRITIS K/C/O DIABETES MILLETUS SINCE 30 YEARS K/C/O HYPERTENSION SINCE 10 YEARS, CHRONIC KIDNEY DISEASE STAGE 4.

ALL THE NECESSARY INVESTIGATION WHERE SENT.

OPTHALMOLOGY REFERRAL ON 20/5/24 I/V/O FUNDOSCOPIC EXAMINATION.

NO EVIDENCE OF DIABETIC OR HYPERTEMDOVE RETINOPATHY CHANGES.

PATIENT TREATED CONSERVATIVELY AND ACCORDINGLY.

PATIENT SYMPTOMS SUBSIDED.

PATIENT DISCHARGED IN HEMODYNAMICALLY STABLE STATE.


PROVISIONAL DIAGNOSIS :-

ACUTE GASTRITIS

K/C/O DIABETES MILLETUS SINCE 30 YEARS

K/C/O HYPERTENSION SINCE 10 YEARS

CHRONIC KIDNEY DISEASE STAGE 4


Investigation:-

RFT 18-05-2024 03:46:PM:-

 UREA39 mg/dl50-17 mg/dl

CREATININE2.4 mg/dl1.3-0.8 mg/dl

URIC ACID4.4 mmol/L7.2-3.5 mmol/L

CALCIUM9.8 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS3.1 mg/dl4.5-2.5 mg/dl

SODIUM139 mmol/L145-136 mmol/L

POTASSIUM4.3 mmol/L.5.1-3.5 mmol/L.

CHLORIDE105 mmol/L98-107 mmol/L

LIVER FUNCTION TEST (LFT) 18-05-2024 03:46:PM :-

Total Bilurubin0.59 mg/dl1-0 mg/dl

Direct Bilurubin0.14 mg/dl0.2-0.0 mg/dl

SGOT(AST)27 IU/L35-0 IU/L

SGPT(ALT)16 IU/L45-0 IU/L

ALKALINE PHOSPHATASE162 IU/L119-56 IU/L

TOTAL PROTEINS6.6 gm/dl8.3-6.4 gm/dl

ALBUMIN4.08 gm/dl4.6-3.2 gm/dl

A/G RATIO1.62

COMPLETE URINE EXAMINATION (CUE) 18-05-2024 03:46:PM:-

 COLOUR-Paleyellow

APPEARANCEClear

REACTIONAcidic

SP.GRAVITY1.010

ALBUMIN - Trace

SUGAR- Nil

BILE SALTS-Nil

BILE PIGMENTS-Nil

PUS CELLS -3-4

EPITHELIAL CELLS -2-3

RED BLOOD CELLS-Nil

CRYSTALS-Nil

CASTS-Nil

AMORPHOUS DEPOSITS-Absent

OTHERS-Nil

HBsAg-RAPID-18- 05-2024 03:46:PM-Negative 

Anti HCV Antibodies - RAPID18-05-2024 03:46:PM:-Non Reactive

hba1c: 6.6%


Treatment Given:-

1. INJ HAI SC/ TID 4U-6U -4U

2. TAB NODOSIS 500 MG PO/OD 0-1-0

3. TAB ECOSPRIN-A 5/10 PO/HS 0-0-1

4. TAB DYTOR PLUS 10/25 PO/OD @ 10 AM

5. TAB CINOD 10 MG PO/BD 1-0-1 .

6. SYP CREMAFFIN 20 ML PO/HS 0-0-1


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