54M Diabetes 4 years, recent Fever Vomitings

Hi, I am J. Harsha Vardhan Foreign Medical Graduate . This is an E-Log, that depicts the patient centered approach for learning medicine .This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post . Hope you learn valuable information after giving it a good read! 

 CHIEF COMPLAINT

A 54 year old male, a construction worker & farmer by profession , came to causality with the complains of

• Fever since 3am in the morning.
• Vomiting since 3am,6am,9am 3 episodes in the morning.
• Throat pain since 7am in the morning.

HISTORY OF PRESENTING ILLNESS

The patient was healthy and asymptomatic 1 month back, then he started to develop itching all over the body.

Went to RMP clinic took medication but itching didn’t subside and it was worsen.

Then patient thought he might be allergic to food (rice) so he decided to stop eating rice but still the itching was persistent.

Then patient felt insulin injection might be the cause for itching so the patient stopped the morning dosage of insulin. but itching didn’t subside than again decided to stop night dosage also without authorised advice from a doctor.

He continued taking the afternoon dosage of Tab.Metformin 500mg PO/OD.

From today morning(3:30am), he started vomiting-

non bilious, non-blood stained, non-projectile, food as content again at 8am total 3 episodes.associated with generalised weakness. 

He also complaints of mild throat pain after vomiting, since 4am this morning, not associated with aggravating or relieving factors. 

At morning 9am patient developed low grade fever, that was insidious in onset, gradually progressing, 
not associated with chills or rigor. 
There were no aggravating or reducing factors. 
On call RMP has visited to their home and gave symptomatic treatment.

Patient lost consciousness at 9 am and was unresponsive.

• No H/O headaches, vision changes, dizziness, seizures.
• No H/O SOB, cold, cough, chest pain, palpitations, orthopnea, PND.
• No H/O loose stools, burning micturition.
• No H/O abdominal pain.

PAST HISTORY 

30 years back patient was completely bed ridden for 15 days due to High grade fever admitted to hospital and recovered.

Again after 5 yrs back then he was hospitalised due to fever & Diagnosed with diabetes during hospitalisation

K/C/O Type II DM, since 5 years.

Medication : 

- Used oral hypoglycaemic agents (OHA) for more than a year 

But sugars were not controlled.

Visited hospital for uncontrolled sugars 

- Shifted to injectable Insulin twice daily. 

• 25units of insulin in the morning
• Tab.Metformin 500mg in the afternoon 
• 20 units of Insulin in the night. 

There is no H/O similar complaints in the past.

• Not a K/C/O HTN, TB, Asthma, Epilepsy, CVA, CAD.
• No H/O surgeries in the past.

FAMILY HISTORY

No fam h/o diabetes 

No significant family history 

PERSONAL HISTORY 

• Appetite - Decreased for the past 10 days.
• Micturition 5-6 times in a day not associated with burning.
• No constipation
• Sleep - adequate 
• Diet - Non-Veg & Mixed (Veg) sometimes 
• Chronic alcoholic since 20 years (daily 90ml)
• No allergies 

Marital status-married 37 years back

• 3 kids 2 sons 1 daughter
• 1 son has expired 
• Son stays out of city with his wife
• Daughter married 
• Patient wakes up at 5am ,goes to farm, 
• drinks tea in between in hotel  
• 7:30am returns to home  eats rice as at 9:30am goes to construction site . 
• 2 pm eats his lunch take rest in home till 3pm goes back to his work ..return home at 7pm 
• Around 8pm takes 90ml alcohol 
• 9:30 eats his dinner (chapati - 5 months back shifted to rice due to pain in jaw) 

• Patient was 4th born out of 5 children
• 1 sister and 3 brothers
• Due to familial issues patient in not in contact with her elder brother
• Small brother was expired 1 year back 

OCCUPATIONAL HISTORY

• Patient is farmer owns fields.
• Daily morning visits his felid and look after them up to 7am 
• 9:30 am goes to Construction site 
• He is also a construction worker and lives at site up to evening 7:30 pm

GENERAL EXAMINATION

Patient was conscious ,coherent , cooperative ,

well oriented.

Pallor-  present

Icterus-absent 

Cyanosis-absent 

Clubbing-absent

Lymphadenopathy-absent

Edema -absent

VITALS (admission)

Temperature-99’F

Pulse rate -130bpm.

Bp-90/70mm hg 

RR-18cpm 

Spo2- 99% 

Grbs- 515mg/dl

SYSTEMIC EXAMINATION:

ABDOMEN:

Soft 

Non tender 

Slightly pallor bulbar conjuctiva

No clubbing of fingers

                                                              No dehydration 

          

CVS: 

S1 and S2 heard. 

No addded thrills or murmurs heard

RESPIRATORY SYSTEM:  

Normal vesicular breath sounds heard. 

Bilateral air entry present.

CNS:

Conscious and coherent.

Normal sensory and motor responses.

INVESTIGATIONS

Hemogram trends 21/07/23 to 22/07/2023

ABG (since joining to till date)

               UKB +

                Increased Serum Osmolality 

          RFT trends (till date)

LFT

Electrolytes 

        

                     ECG

Chest X ray 

Usg- impression

2D Echo

PROVISIONAL DIAGNOSIS: 

The patient is suffering from uncontrolled sugars ?DKA ?HHS with pyrexia ?viral, with K/C/O DM II since 4 years.

TREATMENT: 

on admission 

• IV fluids - NS 2 . Bolus at 100ml/hour

• Inj. HAI 6units IV stat.

• Inj. HAI 1ml in 39ml NS, at 6ml/hour.

(Increase according to GRBS)