GENERAL MEDICINE E-LOG

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

Date of admission: 28/06/22 

CHIEF COMPLAINT: 

A 45 year old male came to opd with chief complaints of 

• Altered sensorium 
• Sweating and with cold peripheries since 1 day 

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 10 years back, then he was diagnosed to have diabetes when he went for a general check up. He was on medication( OHA’s) for his diabetes since 10 years. 

6 years back, patient developed ulcerations on left toe(little finger), which became infected and gangrenous and then his toe was amputated. 

8 months back, he developed similar lesions on left feet and his 4th toe was amputated.

3 months back, patient had a history of diabetic foot ulcer which was developed following a thorn prick injury, following which he developed plantar abscess, necrotising fasciitis with anemia. He had undergone debridment and split skin grafting was done under regional anesthesia. 

1 month back, he had an episode of GTCS with GCS of E3V1M2 and was diagnosed to have hyponatremic seizures with Na+ levels of 117meq/l and Na+ correction was done. 

Patient was alright until yesterday morning, then he skipped his afternoon meal, later he developed sweating, peripheries became cold and developed altered sensorium. 

HISTORY OF PAST ILLNESS: 

K/c/o DM since 10 years 

Not a k/c/o HTN, TB, CAD, Asthma 

TREATMENT HISTORY: 

Patient was on Insulin and OHA’s for his diabetes since 10 years 

PERSONAL HISTORY: 

• Married 
• Occupation: farmer 
• Appetite- normal 
• Having mixed diet( Non vegetarian) 
• Bowels- regular
• Micturition- normal
• Alcohol intake- occasional 
• No habit of smoking 
• No other habits/ addictions 

GENERAL EXAMINATION:

Patient is moderately built and nourished 

Presence of pallor. 

Absence of  Icterus, Clubbing, Cyanosis, Pedal edema, Lymphadenopathy.

                       

VITALS:

1.Temperature: Afebrile 

2.Pulse rate: 70 beats per min

3.Respiratory rate: 18 cycles per min 

4.BP: 110/70 mm Hg

5.SpO2: 97%@Room air 

6.GRBS: 55mg % 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

• S1, S2 heard
• No thrills, No murmurs

RESPIRATORY SYSTEM:

• Normal vesicular breath sounds
• Position of trachea is central
• Dyspnea is absent 
• No wheeze

EXAMINATION OF ABDOMEN:

• Shape- scaphoid
• tenderness- present 
• No palpable pass
• Normal hernial orifices 
• No free fluid
• No Bruits
• Liver is not palpable
• spleen is not palpable
• Bowel sounds heard

CENTRAL NERVOUS SYSTEM:

• Patient was drowsy 
• Altered sensorium 
• No focal neurological defect

PROVISIONAL DIAGNOSIS:

HYPONATREMIA secondary to DM 

INVESTIGATIONS: 

                    

TREATMENT: 

Treatment on 28/06/22: 

1. INJ. PIPTAZ 4.5 GM/IV/Stat 

    INJ. PIPTAZ 2.25 GM/IV/TID 

2. INJ. 3% NACL /IV/ 10ml/hr 

3. INJ. OPTINEURON 1 AMP IN 100ml NS/IV/OD 

4. INJ. PAN 40mg/ IV/ OD 

Treatment on 29/06/22: 

1. INJ. PIPTAZ 4.5 GM/IV/Stat 

2. INJ. 3% NACL /IV/ 10ml/hr 

3. INJ. OPTINEURON 1 AMP IN 100ml NS/IV/OD 

4. INJ. PAN 40mg/ IV/ OD 

5. T.THYRONORM 25microg PO OD