37 year old male with Shortness of Breath

 E-LOG containing investigations :here  

This is the case of a 37 year old male , shopkeeper by profession who presented to the OPD 3 days ago . 

CHIEF COMPLAINTS ; 

The patient presented to the hospital with chief complains of 

• shortness of breath from since the past 5 days 
• burning micturition from the past 5 days  

HISTORY OF PRESENTING ILLNESS 

The patient was apparently asymptomatic 2 years back 

2 years ago the patient developed shortness of breath , profuse sweating , and productive cough .  The patient was taken to the nearby hospital and was diagnosed with Pulmonary Tuberculosis and Type 2 Diabeties Mellitus . 

The Patient was put on the ATT regiment for Pulmonary Tuberculosis . Initially the patient was started on oral hypoglycemic drug for Type 2 diabeties mellitus and was later on shifted to insulin injections. (The patient was not able to recollect the name of the oral hypoglycemic drug or the dosage. ) 

5 days ago the patient experienced a progressively increasing shortness of breath and burning micturition and  was taken to a local hospital (3 days ago ) and shifted to our hospital on the day of admission (3 days ago ).

On examination the patient also complained of pinprick sensation 

PAST HISTORY 

The patient is a known case of 

• Type 2 Diabeties Mellitus since 2 years 
• Pulmonary TB since 2 years 

No history of Asthama or Hypertension . 

DRUG HISTORY : 

Insulin injections from past 2 years  

ATT for 6 months , 2 years back . 

PERSONAL HISTORY : 

Married 

occupation : shopkeeper 

appetite: normal 

Diet : mixed 

Bowel and bladder movement : normal 

no history of alcohol consumption 

the patient has history of smoking , which he quit after being diagnosed for pulmonary tuberculosis one year back . 

sleep - adequate 

FAMILY HISTORY 

No relevant family history . 

GENERAL EXAMINATION 

The patient is concious , coherent , oriented to time place and person . 

Pallor - mild pallor present 

Icterus , cyanosis , clubbing , koilonychyia , lymphadenopathy absent 

The patient complained of a pinprick sensation on his feet 

SYSTEMIC EXAMINATION : 

I. CVS 

• S1, S2 heard
• No murmurs or thrills 

II. RESPIRATORY SYSTEM 

• Reduced breath sounds 

III. PER ABDOMEN 

• No tenderness 
• No free fluid 
• Liver and Spleen- not palpable

IV. CNS 

• The patient is concious coherent and oriented to time place and person 
• Normal higher mental functions 
• Cranial nerves normal 
• Motor functions present 
• Sensory function : PINPRICK SENSATION in the lower extremities (plantar of the foot ) 

PROVISIONAL DIAGNOSIS : 

Diabetic Ketoacidosis secondary to type 2 diabeties mellitus . 

Peripheral Neuropathy 

UTI 

TREATMENT 

1. INJ PANTOP 
2. INJ OPTINEURON
3. INJ CEFTRIAXONE 
4. INJ ZOFER 4MG 1V BD
5. INJ HAI 
6. IVF 5%D @75ML/HR
7. SYP GRILINCTUS 15 ML PO/TID
8. SYP POTCHLOR 15 ML IN 1 GLASS WATER PO/TID