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 


Comments

Post a Comment