Case of a 37 years old male with shortness of breath.

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This is the case of a 37 years old man, who is a shopkeeper by profession.

 CHIEF COMPLAINT

The patient presented to the OPD with the complaint of shortness of breath and burning micturition from 5 days.

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 2 years ago.

 2 years ago, the patient presented to a local hospital with profuse sweating and cough with sputum .He was diagnosed with pulmonary tuberculosis and type II diabetes mellitus. .

The patient was put on ATT for 6 months .He was initially prescribed with oral hypoglycaemic drugs ,but was later shifted to insulin injections.

 The patient experienced severe shortness of breath , 5 days ago. He was taken to the local hospital , which referred him to our hospital, 3 days ago.

On examination, the patient also complained of pin prick like sensations on his feet.

PAST HISTORY

No history of  HTN , Asthma and epilepsy

The patient is a known case of Type II diabetes Mellitus and pulmonary tuberculosis ( diagnosed 2 years ago)

PERSONAL HISTORY

Diet - mixed 

Appetite - decreased 

Sleep -adequate 

Bowel and bladder habits - regular 

Smoking - yes- The patient stopped smoking 2 years ago , when he started experiencing respiratory problems.

FAMILY HISTORY

No relevant family history.

VITALS

 PR =75 bpm 

 RR=  35/min

 TEMP= 98.3 F

 SPO2=99 % at room air. 

 BP=140/90 mmHg

GENERAL EXAMINATION

Patient is conscious , coherent and cooperative.

Moderate built .

Pallor is present.

There is no cyanosis ,icterus,  lymphadenopathy and clubbing .

SYSTEMIC EXAMINATION 

CVS:- 

 S1, S2 heard 

 

RESPIRATORY SYSTEM :- 

 BAE+ 

 NVBS heard 

 PER ABDOMEN :-

No tenderness

No free fluid

No palpable spleen or liver 

CNS

Patient is conscious and coherent.

Speech is normal.

PROVISIONAL DIAGNOSIS-

DKA secondary to Type II diabetes mellitus

Peripheral neuropathy secondary to Type II diabetes mellitus

Urinary tract infection

INVESTIGATIONS-

USG

CUE

URINE KETONE BODIES

HEMOGRAM

 

2D ECHO 

Insulin infusion rate and GRBS monitoring

TREATMENT-

1.IVF - 20 ml/kg/hr iv stat f/b 10ml/kg/hr iv continuous 

2.Inj Pantop 80 mg in 100 ml ns 

3.Inj Actrapid 40 u in 50 ml ns @6 ml/hr 

4.inj actrapid 6 u iv stat 

5.inj Zofer 4 mg IV sos

6.inj Ceftriaxone 1gm iv bd 

7.ivf 5%d @75ml / hr