General medicine-Prefinal practical
case of uncontrolled blood sugar with diabetes foot ulcer
Case
35 year old Male who is a Biochemistry teacher by occupation came to the hospital 13 days ago with the chief complaints of
• Pain in the left lower chest region since 5 days
• Vomitings since 3 days
History of presenting illness
▪Patient was apparently asymptomatic 7 years back then he had fall from bike due to fainting then he was diagnosed as diabetic at local hospital since then he was on medication( metformin- 500 mg) regularly till 2019 and was on regular checkup monthly with dietary practices
▪ He used to drink alcohol occasionally since 2008.He started drinking alcohol heavily (5 days per week and daily 750 ml)since 2019 January due to personal problems and wasn't on regular medications for diabetes
.After 2 weeks he had vomiting and abdominal pain for which he was hospitalized and diagnosed with acute pancreatitis and his blood sugar levels was very high for which he was given insulin , then he was on GLYCOMET -MV1 (metformin and voglibose)
▪ Then he stopped drinking alcohol for 2 months ,during this period of 2 months he was alright
▪ He again started drinking alcohol (5 days per week) and was not regular on diabetic medication and then he had recurrent episodes of abdominal pain following heavy drinking for which he used to stop taking alcohol for 2 days and then he resumes again
▪3 years ago patient had corn on plantar aspect of great toe of left foot, patient himself used to cut the thickened part with a blade, which one year ago turned into an ulcer, for which he underwent debridement 4 months back. He does his own dressing by using spirit to clean the area and then puts iodine and cotton on it, every alternate day but it was not healed and some times he had pain which was radiating upto ankle joint
▪He quit his job 2 years ago and had done suicide attempt ( op poisoning) , since then he was staying at home, but occasionally teaches as a guest lecturer.
▪ 19 days back,he had an accident when he was drunk and then he developed pain and swelling but he neglected it because he was on alcohol totally and did not take any food .Pain which was gradually increased which was throbbing type and non radiating and increased on taking deep breath and on lying on left lateral position , relieved on medication
▪ After 4 days he had single episode of vomiting at night which was blood stained . So he stopped taking alcohol
.Next day he had about 10 to 15 episodes of vomiting which were non bilious initially and bilious there after and non projectile and contents as food particles and
There was sudden increase of pain in lower chest for which he came to our hospital and he had not taken any medication for diabetes since 10days.
He was given Zofer for vomitings and IV fluids were given and his sugar levels were 500-600mg/ dl he was put on Insulin and for first 2 days he was normal ,then he developed itching all over the body but they continued insulin for next 2 days then he had severe itching all over the body ( avil was given) so insulin was stopped and was given oral medication glimiperide 4mg morning , metformin 500 mg morning and glimiperide - 3 mg , metformin 500 mg night. He wants go to de - addiction centre but his sugar levels are not controlled he was sent back
Past history
▪ Known case of diabetes since 8 years
▪No history of hypertension, asthma, epilepsy, CAD
1 year back.. he attempted suicide..( op poisoning)
Family history
Not significant
Personal history
Diet- mixed
Appetite- normal ( does not take food when he consumes alcohol )
Sleep- inadequate( when he does not take alcohol)
Bowel and bladder movements- regular
Habits- consumes alcohol from 2009 occasionally but from 2019 consumed daily -750 ml/day smokes while drinking about 5 to 6 cigarettes each time
General examination
Patient was conscious , coherent, cooperative well oriented to time , place person
Pallor- mild
icterus- absent
cyanosis- absent
clubbing- absent
Lymphadenopathy - absent
Edema- absent
He complained of pain in the 1 St metacarpal joint of both the hands since 3 days
VITALS-
Temp: 98°F
PR: 78bpm
RR: 18 cpm
BP: 120/80 mm hg
SpO2: 98% on RA
GRBS-
• 15/3/2022- 500 to 600 mg/dl
•16/3/2022
2AM (16/3/22): 101mg/dl
6AM (16/3/22): 97 mg/dl
8 AM ( 16/3/22): 144 mg/dl
*From 17th March to 19th March
Before breakfast and dinner -glimiperide 3 mg
After breakfast and dinner -metformin 500 mg
Breakfast -3 idli and ragi Java
Lunch-3 chapathi
Dinner-java+fruits
•18/03/2021
8am- 323mg/dl
10am- 259 mg/ dl
1pm- 251mg/ dl
3pm- 245 mg /dl
7pm -245 mg/ dl
*From 20th March to 23rd march
Patient is on insulin
Breakfast-3 idli+Java
Lunch-3 chapathi
Dinner-java+fruits
•22/3/2022
8am -310 mg /dl
10am - 277mg/ dl
*From 24th to 25th march
Before breakfast and dinner-glimiperide 3 mg
After breakfast and dinner-metformin 500mg
Breakfast-3 idli+ Java
Lunch-3 chapathi
Dinner-fruits+java
•24/3/2022
4 am- 171 mg/dl
7am -341 mg/dl
10am- 250 mg/dl
11am -166 mg/dl
3pm- 341 mg/dl
•25/ 3 /2022
4am -171g/dl
7am -341 mg/dl
1pm- 209 mg/dl
7pm -166 mg/dl
10 pm- 209mg/dl
*From 26th to 29th march
Before breakfast and dinner-glimiperide 4 mg and 3 mg respectively
After breakfast and dinner-metformin 500 mg
Breakfast-idli+java
Lunch-1 cup of rice
Dinner-fruits+java
•26/ 3/2022
7am - 166 mg/dl
10am- 304 mg/dl
3pm- 296mg/dl
7 pm -201mg/dl
10pm- 269mg/dl
•27/ 3/ 2022
6 am- 271 mg/dl
8am- 169 mg/dl
10am-- 306 mg/dl
2pm- 117 mg/dl
4 pm-311 mg/dl
8 pm-376 mg/dl
10pm-334 mg/dl
.28/3/2022
5 am-334 mg/dl
10.40 am-360 mg/dl
1 pm-245 mg/dl
4.40 pm-362 mg/dl
8 pm-225 mg/dl
10.22 pm-232 mg/dl
.29/3/2022
6.30 am-179 mg/dl
11.27am-282 mg/dl
1.30 pm-212 mg/dl
4.30 pm-320 mg/dl
8 pm-259 mg/dl
11pm-301 mg/dl
.30/3/2022
6 am- 176 mg/dl
Systemic examination
S. Amylase: 74 IU/L
Urine for ketone bodies: negative
•LFT:
TB: 1.08
DB: 0.24
AST: 18
ALT: 10
Alk P: 242
TP: 7.3
Alb: 4
A/G: 1.23
•ABG:
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