A CASE OF 71 YEAR OLD MALE

 71 year old male came with the chief complaints of left lower limb pain while walking 

patient was apparently asymptomatic 6 months back and developed left lower limb pain while walking for a short distance and can't walk due to pain and after taking rest the pain was relieved and resumed his walk and has to take multiple breaks to complete his full path

 Past History 

 He was diagnosed as DM II 15 yrs back(as he was admitted to hospital for fever) and is on oral medication and later shifted for insulin therapy

 

 8yrs back he developed decreased urine output for which he got admitted to the hospital and diagnosed for renal calculi for which he got operated


7yr back he got his right great toe amputated I/V/O ?leprosy (decreased sensations on right foot)


2 years back he got left eye operation ? cataract

His right eye got delayed due to high sugars


Personal history

Diet: mixed

Appetite:normal

Sleep: adequate

Bowel & Bladder: regular

Addiction:

Smoking 3-5ciggs/day since he was 30yrs of age 

Stopped 2yrs back

Alcohol since 30yrs of age only on occasions


O/E

Pt is c/c/c

No signs of pallor, icterus, cyanosis, clubbing, lymphadenoapathy, edema


Vitals:

Temp:97.5f

PR: 92 bpm, regular

RR: 26 cpm

BP: 140/70 mmHg

SPO2:

AT ROOM AIR-96%

GRBS:126 mg/dl

Systemic examination :

CVS:S1,S2 heard

Apex beat:5th ICS

Resp:

       BAE+(vesicular breath sounds)

         Nvbs heard

           Position of trachea- central

  P/A: soft, tenderness absent, bowel sounds heard

  Cns: NFND

On day 1 of admission 

Patient developed high sugars during night time and was shifted to ICU for the same

Rx: 

1. IVF NS, RL@100ml/hr

2. Inj.HAI S/C premeal TID

        8am--1pm--8pm

3. Tab.MVT PO/OD

4. Temp charting 4th hourly


Day 2:

SUBJECTIVE:

NO SUBJECTIVE COMPLAINTS


OBJECTIVE

Temperature-97 F

Bp-120/60 mmhg

PR- 72bpm

RR -11 cpm

GRBS - 196 gm/dl(14IU HAI)

CVS:S1,S2 heard

Apex beat:5th ICS

Resp:BAE+(vesicular breath sounds)

            Nvbs heard

             Position of trachea- central

  P/A: soft, tenderness absent, bowel sounds heard

                               Cns: NFND



ASSESSMENT-

Uncontrolled Sugars with K/C/O DM II


PLAN OF CARE- 

1. IVF NS, RL@100ml/hr

2. 2. Inj.HAI S/C premeal TID

3. 8am--1pm--8pm

4. 3. Tab.MVT PO/OD

5. 4. Temp charting 4th hourly


Day 3

SUBJECTIVE:

NO SUBJECTIVE COMPLAINTS


OBJECTIVE

Temperature-97 F

Bp-120/60 mmhg

PR- 72bpm

RR -11 cpm

GRBS - 196 gm/dl(14IU HAI)

CVS:S1,S2 heard

Apex beat:5th ICS

Resp:BAE+(vesicular breath sounds)

            Nvbs heard

            Position of trachea- central

 P/A: soft, tenderness absent, bowel sounds heard

 Cns: NFND


ASSESSMENT-

Uncontrolled Sugars with K/C/O DM II

















PLAN OF CARE- 

1. IVF NS, RL@100ml/hr

2. Inj.HAI S/C premeal TID

        8am--1pm--8pm

4.Tab.MVT PO/OD

5. Temp charting 4th hourly


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