35 year old male with uncontrolled sugars

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment 

Case:

35 year old male farmer by occupation is brought to opd with 

C/O vomiting since 8 days.

History of presenting illness:-

Patient was apparently asymptomatic one month back. He then has occasional episodes of vomitings which are increased in frequency since past  8 days that is of  1 - 2 episodes per day,Non projectile,Non bilious,Not blood tinged,Food particles as content associated with fever,Not associated with pain abdomen

8 months back patient suffered with ? Chickenpox for 1.5 month .

2months after recovery from chicken pox he is diagnosed as having  DM (probably type 1)when patient presented with unconscious state

H/o of  shortness of breath( grade 2) for 1 month  which is intermittent ( increased during night),Associated with cough and fever

Burning micturation present

Cough initially Non productive later productive ,Associated with scanty sputum,Non blood tinged

Fever is low grade, intermittent,associated with night sweats not associated with chills and rigors   

Weight loss (8 to 10 kg)  from past 3 months

Progressive increase in weakness which is  increased in severity since past 10days 

Decreased appetite since past 1 month 

Since 4months he was on Mixtard  10 units once daily for his DM 

But Patient stopped takimg medication since  1 month 

N/k/c/o htn asthma,CAD,TB,epilepsy

Non alcoholic,Non smoker,No relevant family history 

Treated outside for UTI - ecoli  with antibiotics

Vitals - 

Bp:- 140/80 mmHg

PR :-123bpm.

Sat- 100 on RA

Grbs - High at presentation

RR- 26cpm

Temp- 100°F

Systemic examination:-

Cvs - S1S2

Rs- B/L air entry present

Started on ivf NS bolus f/b 75ml/hr 

Inj Hai 6u IV hourly---> infusion @6u/hr

2d echo - ivc 1.28cm ,collapsible

Normal chambers

Mild lvh

Hemogram:- 

Hb-7.2

TLc- 22,800

Plt- 3.3 lakhs

Microcytic hypochromic

Urea-206

Creat 4.0

Na-131

K-4.7

Cl- 95

Urine for ketones negative

Rbs- 485 mg/dl 

Course in the hospital:- patient presented to our hospital with the above mentioned complaints, thorough clinical and metabolic evaluation was done. 

GRBS was high, RBS was 485mg/dl, urine for ketones was negative and ABG showed metabolic acidosis 

Patient was treated for uncontrolled sugars with insulin Inj.Hai @6ml/hr infusion and tapered the insulin according to the GRBS blood sugar levels were controlled.

As the patient was having recurrent Urinary tract infections and fever spikes USG abdomen was done which showed b/l bulky kidneys with altered echo texture suggestive of pyelonephritis and left sided hydroureteronephrosis .

Urology opinion was taken ivo bilateral pyelonephritis and CT-KUB was advised , IV Antibiotics Inj.Piptaz 2.25gm /IV/TID was    given for 4days

Ophthalmology referral done showed :- mild NPDR changes noted and adviced strict glycemic control, review to opthalmology opinion for every 6 months,

Date-12/4/23 Urine culture report showed methicillin sensitivity staphylococcus aureus resistance to penicillins and sensitivity to co trimaxazole ,….and I/v/o renal failure creatinine clearnce 23ml/hr cotrimoxazole (Dose adjustement was done(50%of regular dose) was given for 5 days .

I/v/o anaemia evaluation was done, Hb-7.2 gm/dl,Microcytic hypo chronic ,Reticount :-0.5

Stool for occult blood( + )

Surgery opinion was taken I/v/o previous h/o hemorrhoids and constipation 

P/R examination showed - skin around the glutial clefts normal 

-no external skin tags, fissures, haemorrhoids, sinuses or fistulas 

-surrounding external skin stained with stool .

-anal tone is normal

-hard stoll pellets found in the rectum

- all stool pellets have been cleaned upto the level of finger insertion.

-glove stained with dark yellow coloured stool 

Adviced - syp cremaffin 30ml/po/hs 

-proctoscopy after soap water enema 

- advice colonoscopy to rule out  losses ,gi bleed 

-upper GI endoscopy i/v/o any upper GI bleed 

Upper GI endoscopy was planned I/v/o any upper GI bleed which showed esophageal candidiasis, bile reflux gastritis 

Endocrinology opinion was taken and was suggested Inj Lantus 10 units at @10pm

Urology opinion was taken again  and Fosfomycin 3gm sachets alternative days for 1 week (3 doses) if patient did not improve symptomatically. 

Nephrology opinion was taken for presence of ? Diabetic nephropathy and was suggested tab lasix 20mg PO OD for 3days

INVESTIGATIONS :- 

Hemogram:-

Hb:- 7.2----6.2----6.8----6.0--6.0

Pcv:- 22.5----20.4----22.5----19.9--19.9

TLC:- 22,800----14,480---9,500----7500-- 7300

RBC:- 3.3----2.89----3.16----2.81--2.78

Platelets:-4.2----3.47----4.0----4.18--4.10

RETICULOCYTE COUNT   :- 0.5

RFT :-

Blood urea:- 206----147----77----60--35

Sr creatinine:- 4.0----3.4----2.3----2.3--2.6

S.Na:- 131----139----137----139--139

S.K:- 4.7----4.0----3.8----3.8--3.7

S.Cl:- 95----104----106----104 

Ionized Ca:- 1.04--1.08--1.07--1.13

LFT:-

Total bilirubin:- 1.04

Direct bilirubin:- 0.23

SGPT:- 14

SGOT:-11

ALP:- 284

TOTAL PROTEIN:- 8.0

Albumin :- 2.5

A/G ration:- 0.45  

24 hour URINARY ELECTROLYTES:-

Na:- 176 

Ca :- 297 

Phosphorous:-0.87 

USG report:- 

Review USG:- 

2D echo report:- 

Upper GI endoscopy:-

Chest x ray:-

Xray kUB-

ECG:- 

CT:- 

Report

C& S blood and urine:-

DIAGNOSIS:- 

Uncontrolled sugars secondary to non compliance to medication. (Resolved )

Acute kidney injury secondary to? Pre renal secondary to ? Sepsis ?

bilateral pyelonephritis with left hydroureteronephrosis 

with anemia (microcytic hypochromic) secondary to?

GI losses 

? Iron deficiency anemia 

Treatment Given :- 

1.IVF- NS @ 75ml/hr

2.Insulin infusion @8 U/hr increase or decrease acc to GRBS(algorithm 2)

3.GRBS charting hourly and inform PG

4.Monitor Temp, PR,RR,BP hourly

5.Strict input output charting. 

6.trimethoprim + sulphamethoxazole is given for 5 days starting from 16th