Uncontrolled diabetes

 Date of admission - 02/09/2023

CHIEF COMPLAINTS :

A 65 year old male patient presented to the opd with chief complaint loss of consciousness which was associated with sweating . 

There was no history of nausea , vomiting , pain abdomen, headache and burning micturition . 

HISTORY OF PRESENT ILLNESS  : 

Patient was apparently asymptomatic 15 days ago and then he had and incident of thorn prick in the right leg and he visited the local hospital where they had incised and removed the thorn and then the swelling in the right increased and there was blister formation in the right leg and he was referred to higher centres where they diagnosed him to have high Creatine levels and then was referred to another higher centre where haemodialysis was done and debridement of the blisters were done . 

After being discharged from the hospital he lost consciousness and was admitted to our hospital . 

HISTORY OF PAST ILLNESS : 

K/C/O DM 2 since 10 years 

Was on medication s

NIK/CIO HTN, TB, EPILEPSY, THYROID DISORDER, CVA, CAD AND BRONCHIAL ASTHMA

PERSONAL HISTORY : 

SLEEP-ADEQUATE

DIET-MIXED

APETITE-NORMAL

ADDICTIONS-NONE 

ALLERGIES-NONE

FAMILY HISTORY : 

Not significant 

O/E:

PT IS C C C

BP: 100/70MMHGMMHG

PR :84BPM

RR: 18CPM

SPO2: 98% AT ROOM TEMP

NO SIGNS OF PALLOR ICTERUS CLUBBING CYANOSIS LYMPHADENOPATHY

S/E:

CVS: S12 PRESENT

CNS: NAD

RS: NVBS HEARD

INVESTIGATIONS : 

                               1) C reactive protein : 

                           2) Erythrocyte sedimentation rate : 

                  3) Bleeding and clotting time : 

                        4) blood sugar fasting : 

5) lipid profile : 

6) RFT 

8) serum iron 

9) blood lactate 

10 ) RFT 

PROVISIONAL DIAGNOSIS : 

 AKI associated with Sepsis

 POD -I Debridement

Right lower Limb cellulitis 

TREATMENT : 

4IV FLUIDS NS@U.O+30ML/H

INJ PIPTAZ 2.25G IV/BD

INJ METROGYL 500MG IV/TID

INJ HAI S/C TID

INJ LASIX 40MG IV/BD

TAB ALDACTONE 25MG PO/BD