50 Yr Male with Uncontrolled Sugars

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Case in brief
A 50yr old male ,farmer by occupation came to opd ,for deaddiction 
Chief complaints
• Generalized weakness since 15days 
• Polydipsia
• Polyuria 

History of present illness
• Patient was apparently asymptomatic 1yr back then he was diagnosed to have diabetes at a government camp.
• So then he was given oral antigycemic drugs ,he used it for 2months and stopped it.
• So, he developed generalized weakness, polydipsia, polyuria.
• Then he visited a private hospital at nakrekal,then was found to have high sugar levels ,since then he was started with insulin,but he was on a irregular medication. 

History of past illness
• He was a k/c/o of type 2 diabetes 1year back.
• He was not a k/c/o hypertension, asthma,CAD, epilepsy

Treatment history
• He was on diabetic medication
• No history of use of any other medication 

Family history
• There is no significant family history 

Personal history
• Mixed diet 
• Normal appetite
• Normal bowel movements
• No known allergies
• Adequate sleep
• Habits-
• chronic alcoholic -180ml/day since 30yrs
     Tobacco smoking(beedi) since 30yrs 1pack/day
• Daily routine- He generally wakes up at 6:00am in the morning and at 7:00am he'll have his breakfast(rice) .And the goes for farming ,and then he'll have his lunch at 2:00pm and returns from farming at 6:00 in the evening and drinks alcohol and goes to bed around 9:00pm. 

GENERAL EXAMINATION 

on Examination,
patient is conscious,coherent,co - operative and well Oriented to time,place and person. 

There are no signs of 

Icterus,cyanosis,clubbing,Lymphadenopathy and oedema 

There is presence of mild pallor.  

VITALS
Temperature: 98°F
PR: 82bpm
BP:90/60
RR:18/min
RBS-541mg/dl 

Sytemic examination 

C VS:
No thrills 

S1 and S2 + 

NO murmurs 

Respiratory system 

NO Dyspnoea 

NOWheeze 

Trachea is centrally located 

Abdomen 

soft and non tender 

NO palpable Mass 

Liver and Spleen are not palpable 

CNS

NAD 

Investigations:


Ultra sound
Fatty infilteration of liver 

Mild hepatomegaly

Coarse texture of liver 


DIAGNOSIS 

Uncontrolled Diabetes 

TREATMENT
27/7/22
• Tab.BENFOTIAMINE PO/OD
• TAB.GLIMI -M1 PO/OD
• INJ. HAI 6units S.C
• GRBS monitoring 

28/7/22 

• Tab.BENFOTIAMINE PO/OD
• TAB.GLIMI -M1 PO/OD
• INJ. HAI 6units S.C
• GRBS monitoring

29/7/22
.Tab. BENFOTIAMINE PO/BD 
 Tab. GLIMI -M1 PO/BD 
Tab PREGABA- M 75mg 

Vitals 
29/07/22
BP 110/70mmHg
PR 68/min 
3pm - 325
  7pm - 466 - Tab.Glimi 2.5mg 
                      Tab metformin 1g/dl

   12am- Hi - HAI units SC
   4am - 177

  31/07/22
  8am - 239 
  1am - 348
   2pm- 324
   4pm-528 Glimi 4mg metformin 1g/dl
   10pm-345
    2am- Hi Glimi 4mg metformin 1g/dl

  01/08/22
  Glimi 4mg metformin 1g/dl
 8am-288 
 10am-352 
 1pm-200 
 4pm-394
 8pm-338 - Glimi 4mg metformin 1g/dl
 11pm-333
 2am-336
 
02/8/22 
Glimi 4mg metformin 1g/dl
 8am-155
 11:30am -318
 5:00pm-394
 8:00pm- 338
 10:30pm-477
 2:00am-362

 03/08/22
 8:00am-135
 12pm - 300
  8pm - 532
  10pm - 411
  2am - 320
  
04/08/22
 8am - 176
 

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