Case 18 - A 50 year old man k/c/o DM presenting with fatigue and excessive sweating.

A 50 year old man k/c/o DM presenting with fatigue and excessive sweating.

Hi, I am R. Ramya Keerthana, 5th semester medical student. 

This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 

I've 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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

Case Scenario

General Medicine Ward

DOA: 19-06-23

A 50 year old man resident of Lingotam came to OPD with chief complaints of: 

- fatigue since 1 day

- excessive sweating since 1 day

History of Presenting Illness

- patient was apparently asymptomatic 4 days ago when he developed fatigue and excessive sweating and was brought to casualty. He was diagnosed with hypoglycemia and given glucose infusion following which he recovered and was sent home.

- 1 day ago he again developed similar symptoms and came to OPD.

- after coming to the hospital, he developed:

1. Loose stools 3 days ago - 3 episodes per day for 3 days

2. Vomiting 3 days ago - 1 episode per day for 2 days, non-projectile and non-bilious

3. Fever with chills, high grade, continuous and relieved on medication 3 days ago, associated with blurring of vision

4. Burning micturition 3 days ago

5. SOB Grade 4 

- no h/I headache, chest pain, pain abdomen, LOC, polyuria or reduced urine output.

Daily Routine

- Before being hospitalized, he used to wake up at 3am, walk for 10 mins, go to the bathroom and sleep and wake up at 5am. He would then have breakfast (upma/idli,etc) tea and take DM medication and head to work as a auto driver. He would have rice and tea for lunch and return home at 8pm, have rice for dinner and go to sleep.

- Since being hospitalized, he wakes up at 6am, and either doesn't eat or eats very little breakfast and lunch due to lack of appetite. He eats upma or bread-milk for dinner and goes to sleep. He stays in bed for most of time.

Past History

- k/c/o DM since 10 years in regular medication (Formin-SR 500)

- lipoma on right shoulder since childhood

- n/k/c/o HTN, TB, CAD, epilepsy, asthma, thyroid disorder

- no h/o of blood transfusions.

Surgical History

- left eye cataract surgery 12 years ago

- right eye cataract surgery 11 years ago.

Personal History

- married

- Used to work as a auto driver but stopped working since 6 months due to blurring of vision 

- mixed diet 

- decreased appetite since 4 days 

- adequate sleep

- increased bowel movements 

- burning micturition

- no known allergies

- chronic smoker- 2 pacs/day

- occasional alcoholic

Family History

- not significant 

Drug History

Tab. Formin-SR 500 OD in the morning since 10 years 

General Examination

I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room. 

- patient was conscious, coherent and cooperative

- well oriented to time and space

- well built and adequately nourished

- no pallor

- no icterus

- no cyanosis 

- no clubbing of fingers

- no lymphadenopathy 

- no pedal edema 

- no malnutrition 

- no dehydration 

Vitals

- Temperature: afebrile 

- Pulse rate: 71 bpm, regular rhythm, normal volume

- Respiratory rate: 33 cpm

- BP: 110/70 mm Hg

- SPO2: 98% at RA

- GRBS: 173 mg/dl

Fluid Intake and Urine Output

Total Input: 3200 ml

Total Output: 2200 ml

Fever Chart

Systemic Examination

CARDIOVASCULAR SYSTEM

Inspection : 

-Shape of chest: elliptical 

-No engorged veins, scars, visible pulsations

Palpation :

-Apex beat can be palpable in 5th intercostal space

- no cardiac thrills 

Auscultation : 

- S1,S2 are heard

- no murmurs

RESPIRATORY SYSTEM

Patient examined in sitting position

Inspection:

- Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 

-Chest appears Bilaterally symmetrical & elliptical in shape

- No dyspnea and wheezing 

-Respiratory movements appear equal on both sides and it's abdominothoracic type. 

-Trachea central in position & Nipples are in 5th Intercoastal space

-No dilated veins,sinuses, visible pulsations.

Palpation:

-All inspiratory findings confirmed

-Trachea central in position

Percussion: Resonant 

Auscultation:

-Supraclavicular- (NVBS) (NVBS)

-Infraclavicular- (NVBS) (NVBS)

-Supraammary- (NVBS) (NVBS)

-Inframammary- (NVBS) (NVBS)

-Axillary- (NVBS) (NVBS)

-Infra axillary-(NVBS) (NVBS)                 

-Suprascapular- (NVBS) (NVBS)

-Interscapular- (NVBS)

-Infrascapular- (NVBS)(NVBS)

ABDOMEN 

- shape: scaphoid

- no tenderness

- no palpable mass

- no bruits

- no free fluid

- hernias orifices: normal

- liver: not palpable 

- spleen : not palpable

- bowel sounds heard

- genitals:

- speculum examination :

- P/R examination : 

CENTRAL NERVOUS SYSTEM

- conscious 

- normal speech

- no neck stiffness

- no Kerning's sign

- cranial nerves: normal

- sensory : normal

- motor: normal

- reflexes: all present bilaterally

- finger nose in coordination: no 

- knee heel in coordination: no

- gait: normal

Investigations

Biochemical:

USG:

ECG:

Provisional Diagnosis

- RECURRENT HYPOGLYCEMIA 

Treatment