60 year old male patient who is a RTC driver ,came with the complaints of increased frequency of micturition during night (4 to 5 times every night) ( nocturia)
increased thirst since 3 months
sensation of bladder fullness present
No h/o fever,weight loss,loss of appetite,chest pain,SOB,PND,orthopnea,pain abdomen,burning micturition,pedal edema,
blurring of vision( left eye) since 3 months
No h/o,vomitings,diarrhea
No h/o tingling and numbness of both upperlimb and lower limb
Bowel and bladder movements are regular
PAST HISTORY:
K/C/O HTN since 10 years
PERSONAL HISTORY:
Diet : mixed
Appetite: normal
sleep: adequate
Bowel and bladder movements : regular
Addictions: drinks 90 to 180 ml / day every day since 40 yrs
smokes 10 beedis / day since 40 years
DRUG HISTORY:
TAB Amlodipine 5 mg
TAB Atenolol 50 mg for hypertension since 9 yrs
GENERAL EXAMINATION:
Pt is conscious , coherent and cooperative
moderately built and nourished
BP:150/100 mmHg
PR: 75 bpm
TEMPERATURE: afebrile
RR:16 cpm
NO pallor,icterus, cyanosis,clubbing, lymphadenopathy,edema
SYSTEMIC EXAMINATION:
CVS Examination:
S1,S2 Heard
No murmurs
RESPIRATORY EXAMINATION:
position of trachea: central
normal vesicular breath sounds present
No adventitious sounds
PER ABDOMEN EXAMINATION:
No scars ,no visible pulasations
No tenderness
No palpable mass,all the hernial orifices are free
spleen amd liver not palpable
CNS EXAMINATION:
Patient is conscious,
speech is normal
no signs of meningeal irritation
Cranial nerves : intact
Reflexes:
Biceps. Triceps. supinator. knee. ankle
RIGHT. +2. +2. +2. +2. +2
LEFT. +2. +2. +2. +2 +2
Gait : normal
GCS :15/15
Hemogram:
Hb:14.8
TC:9300
PCV 41.8
MCV:88.6
MCH:31.3
RBC Count:4.72 million
platelet count: 1.87 lakhs
smear : normocytic normochromic
CUE:
Colour : pale yellow
appearance : clear
Reaction: acidic
specific gravity : 1.010
sugar ++++
albumin +
pus cells 2 to 4
epithelial cells 2 to 3
RBC Nil
crystals nil
casts nils
FBS :309
PLBS :536
Hba1 c :8.1%
ABG
pH : 7.4
Pco2 : 33.5
po2 :88.4
serum creatinine: 1.0
blood urea : 29
RFT : Urea :42
creatinine: 0 .8
uric acid: 1.9
calcium 10.0
sodium 133
potassium 3.7
chlorine 98
phosphate 2.8
urine for ketone bodies : negative
Lipid profile:
Total cholesterol : 136
Triglycerides 310
HDL: 50
LDL:82
VLDL:62
Spot urine protein : 31.5
spot urine creatinine:85.0
ratio:0.37
DIAGNOSIS:
Denovo DM TYPE 2 with K/C/O HTN with hypertriglyceridemia ( metabolic syndrome)
TREATMENT GIVEN:
TAB Telma AM(40/5) OD
TAB Glimiperide BD
Morning 2 mg night 1.5 mg
TAB Metformin 500 mg / BD
TAB Atorvastatin 20 mg H/S
Strict diabetic diet and exercise
GRBS charting
watch for hypoglycemic symptoms
Monitor PR RR BP
ADVICE AT DISCHARGE:
TAB Telma AM(40/5) OD
TAB Glimiperide BD
Morning 2 mg night 1.5 mg
TAB Metformin 500 mg / BD
TAM Atorvastatin 20 mg H/S
Home GRBS monitoring
Watch for hypoglycemic symptoms
