50 yr old male patient

50 Year old male patient

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CASE IN BRIEF:

A 50yr old male ,farmer by occupation came to opd ,for deaddiction 

Chief complaints

• Generalized weakness since 15days 

• Polydipsia

• Polyuria 

History of present illness

• Patient was apparently asymptomatic 1yr back then he was diagnosed to have diabetes at a government camp.

• So then he was given oral antiglycemic drugs ,he used it for 2months and stopped it.

• So, he developed generalized weakness, polydipsia, polyuria.

• Then he visited a private hospital at nakrekal,then was found to have high sugar levels ,since then he was started with insulin,but he was on a irregular medication. 

History of past illness

• He was a k/c/o of type 2 diabetes 1year back.

• He was not a k/c/o hypertension, asthma,CAD, epilepsy

Treatment history

• He was on diabetic medication

• No history of use of any other medication 

Family history

• There is no significant family history 

Personal history

• Mixed diet 

• Normal appetite

• Normal bowel movements

• No known allergies

• Adequate sleep

• Habits-

• chronic alcoholic -180ml/day since 30yrs

     Tobacco smoking(beedi) since 30yrs 1pack/day

• Daily routine- He generally wakes up at 6:00am in the morning and at 7:00am he'll have his breakfast(rice) .And the goes for farming ,and then he'll have his lunch at 2:00pm and returns from farming at 6:00 in the evening and drinks alcohol and goes to bed around 9:00pm. 

GENERAL EXAMINATION 

on Examination,

patient is conscious,coherent,co - operative and well Oriented to time,place and person. 

There are no signs of 

Icterus,cyanosis,clubbing,Lymphadenopathy and oedema 

There is presence of mild pallor.  

VITALS

Temperature: 98°F

PR: 82bpm

BP:90/60

RR:18/min

RBS-541mg/dl 

Sytemic examination 

CVS:

No thrills 

S1 and S2 + 

NO murmurs 

Respiratory system: 

NO Dyspnoea 

NOWheeze 

Trachea is centrally located 

Abdomen:

soft and non tender 

NO palpable Mass 

Liver and Spleen are not palpable 

CNS:

NAD 

  Investigations:

Ultra sound

Fatty infilteration of liver 

Mild hepatomegaly

Coarse texture of liver 

DIAGNOSIS 

Uncontrolled Diabetes 

TREATMENT

27/7/22

• Tab.BENFOTIAMINE PO/OD

• TAB.GLIMI -M1 PO/OD

• INJ. HAI 6units S.C

• GRBS monitoring 

28/7/22 

• Tab.BENFOTIAMINE PO/OD

• TAB.GLIMI -M1 PO/OD

• INJ. HAI 6units S.C

• GRBS monitoring

29/7/22

.Tab. BENFOTIAMINE PO/BD 

 Tab. GLIMI -M1 PO/BD 

Tab PREGABA- M 75mg 

Vitals:

29/07/22

BP 110/70mmHg

PR 68/min 

3pm - 325

  7pm - 466 - Tab.Glimi 2.5mg 

                      Tab metformin 1g/dl

   12am- Hi - HAI units SC

   4am - 177

  31/07/22

  8am - 239 

  1am - 348

   2pm- 324

   4pm-528 Glimi 4mg metformin 1g/dl

   10pm-345

    2am- Hi Glimi 4mg metformin 1g/dl

  01/08/22

  Glimi 4mg metformin 1g/dl

 8am-288 

 10am-352 

 1pm-200 

 4pm-394

 8pm-338 - Glimi 4mg metformin 1g/dl

 11pm-333

 2am-336

 

02/8/22 

Glimi 4mg metformin 1g/dl

 8am-155

 11:30am -318

 5:00pm-394

 8:00pm- 338

 10:30pm-477

 2:00am-362

 03/08/22

 8:00am-135

 12pm - 300

  8pm - 532

  10pm - 411

  2am - 320

  

04/08/22

 8am - 176

06/08/22

 10:30 am-272