7.

 Case History and Clinical Findings

A 71 YEAR OLD MALE PATIENT WAS BROUGHT TO THE CASUALITY IN AN UNCONSCIOUS STATE .PATIENT WAS

APPARENTLY NORMAL UNTIL 9PM YESTERDAY NIGHT , THEN HE SUDDENLY WENT INTO

THE STATE OF UNCONSCIOUSNESS AFTER EATING FOOD , NOT ASSOCIATED WITH

VOMITING , SEIZURES,CHEST PIAN , PALPITATIONS , INVOLUNTARY MICTURITION ,

FROATHING FROM MOUTH .NO H/O FALL , TRAUMA TO HEAD,GIDDINESS ,FEVER , BURNING

MICTURITION.

PAST HISTORY:K/C/O DM SINCE 20YEARS AND ON T.GLIMI M1

NO H/O HTN/EPILEPSY/TB/CVD/CAD

H/O TRAUMA TO RIGHT LOWER LIMB FOR WHICH TIMELY INTERVENTION WAS DONE AT A

LOCAL HOSPITAL , BUT STILL GANGRENOUS GREAT TOE +

PERSONAL HISTORY :

APPETITE - NORMAL

DIET - MIXED

BOWEL AND BLADDER - REGULAR

SLEEP - ADEQUATE

GENERAL EXAMINATION :

PT IS C/C/C

NO PALLOR, ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY,PEDAL EDEMA

VITALS ON ADMISSION:

TEMP- 98.5

PR-90 BPM

BP- 160/90MM HG

RR-16 CPM

SPO2- 100% AT RA

GRBS - 33 MG/DL

SYSTEMIC EXAMINATION:

1) PER ABDOMEN:

INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY

WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY.

ASCULTATION: BOWEL SOUNDS - HEARD

2)RESPIRATORY SYSTEM:

INSPECTION:SHAPE OF THE CHEST IS ELLIPTICAL,B/L SYMMETRICAL.BOTH SIDES MOVING

EQUALLY WITH RESPIRATION..NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS ,TRACHEA IS CENTRAL

IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL .VOCAL FREMITUS IS NORMAL

PERCUSSION: RESONANT B/L

ASCULTATION: BAE + , NVBS HEARD, LEFT IMA CREPTS +

3) CVS:

INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO

SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

PALPATION: APEX BEAT FELT IN LEFT 5TH ICS.NO THRILLS AND PARASTERNAL HEAVES.

ASCULTATION: S1S2 +,NO MURMURS

4) CNS:

PATIENT WAS C/C/C.

HIGHER MENTAL FUNCTIONS- INTACT

GCS - E4V5M6

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEMNORMAL,

MOTOR SYSTEM: TONE- NORMAL, POWER- 5/5 IN ALL LIMBS

REFLEXES : BICEPS - 1+ , TRICEPS-1+ , SUPINATOR - ,KNEE - 1+ , ANKLE - 1+

REFERRALS TAKEN:

1. OPTHALMOLOGY :I/V/O RAISED ICT - FUNDUS EXAMINATION REVEALED CATARACTOUS

LENS- ADVISED B/L CATARACT SURGERY

2. SURGERY:I/V/O RIGHT GREAT TOE GANGRENE- SUGGESTED RAY AMPUTATION UNDER

SA OR ANKLE BLOCK.

BRIEF COURSE IN HOSPITAL:

PATIENT WAS BROUGHT TO CASUALITY WITH ABOVE MENTIONED COMPLAINTS AND

NECESSARRY INVESTIGATIONS WERE SENT AND AS PATIENT WAS UNCONSCIOUS UPON

EVALUATION HIS GRBS WAS 33 MG/DL FOR WHICH 25D WAS GIVEN , POST WHICH HE

REGAINED CONSCIOUSNESS. INSPITE OF 25 D INFUSION PATIENT HAD REPEATED

EPISODES OF HYPOGLYCEMIA FOR WHICH HE WAS TREATED SYMPTOMATICALLY. AFTER

PATIENT WAS STABILISED SURGERY RFERRAL WAS TAKENI/V/O RIGHT GREAT TOE

GANGRENE- SUGGESTED RAY AMPUTATION UNDER SA OR ANKLE BLOCK . SO DOPPLER

OF RIGHT LOWER LIMB WAS DONE ,WHICH SHOWED: NO FLOW SEEN IN DISTAL

PTA.POPLITEAL,PROXIMAL PTA, ATA DPA SHOWS BIPHASIC WAVEFORM LIKELY PVD,NO

DVT ,MODERATE ATHEROSCLERTIC CHANGES NOTED IN EXAMINED ARTERIES.FOLLOWING

THIS, NOW THE PATIENT IS BEING REFERRED TO KHL FOR REVASCULARIZATION SURGERY

OF RIGHT LOWER LIMB .

Investigation

1.HEMOGRAM:

4/02/23

HB:7.3 MG/DL

TLC: 12000 CELLS/CUMM

PLAT: 2.9 LAKH/CUMM

7/02/23

HB : 6.3 mg/dl

PCV : 34.4%

TLC : 6900 CELLS/CUMM

PLT : 3.2 LAKH/CUMM

2. USG ABDOMEN:

RIGHT GRADE 3 RPD CHANGES

LEFT GRADE 2 RPD CHANGES

B/L SIMPLE RENAL CORTICAL CYST

GRADE 1 PROSTOMEGALY

3. DOPPLER OF RIGHT LOWER LIMB:

NO FLOW SEEN IN DISTAL PTA.

POPLITEAL,PROXIMAL PTA, ATA DPA SHOWS BIPHASIC WAVEFORM LIKELY PVD

NO DVT

MODERATE ATHEROSCLERTIC CHANGES NOTED IN EXAMINED ARTERIES.

4)2D ECHO : NO RWMA , MILD LVH+

MODERATE TR+ WITH PAH

MILD AR+/ MR+, MILD GLOBAL HYPOKINESIA ,NO AS/MS

SCLEROTIC AV,

EF=50%

FAIR LV SYSTOLIC FUNCTION, DIASTOLIC DYSFUNCTION +, NO PE.

5) URINE C/S: NO GROWTH DETECTED

Diagnosis ALTERED SENSORIUM SECONDARY TO HYPOGLYCEMIA (RESOLVED), ? OHA INDUCED HYPOGLYCEMIA, HFmEF (EF :50%), RIGHT GREAT TOE GANGRENE WITH AKI ON CKD ANEMIA UNDER EVALUATION ?IDA HYPERKALEMIA (RESOLVED) DM SINCE : 20 YEARS

Treatment Given(Enter only Generic Name)

1.IVF 1NS @ 75 ML/HR

2.INJ CEFTRIAXONE 1 GM IV BD - D3 ON 7/2/23

3.INJ LASIX 40 MG IV BD

4.T ECOSPIRIN GOLD 75/75/20 PO HS

5.T RAMIPRIL 2.5 MG PO OD

6.T CARVIDIOL 3.125 MG PO OD

7.T OROFER XT PO OD

8.PLENTY OF ORAL FLUIDS

9.INJ HAI S/C ACC TO GRBS

Advice at Discharge

1.T TAXIM 200 MG PO BD

2.T LASIX 40 MG PO BD 8AM ------4PM

3.T ECOSPIRIN GOLD 75/75/20 PO HS

4.T RAMIPRIL 2.5 MG PO OD

5.T CARVIDIOL 3.125 MG PO OD

6.T OROFER XT PO OD

7.INJ HUMAN ACTRAPID INSULIN 6U---6U---6U

REFERRED TO HIGHER CENTER I/V/O REQUIREMENT OF VASCULAR SURGEON FOR

REVASCULARISATION OF RIGHT LOWER LIMB.

Follow Up

REVIEW AFTER 1WEEK WITH FBS,PLBS,HBA1C REPORTS