Case Sheet

A 50 year old male who's a resident of nakrekal,labourer by occupation came to the opd to get admitted under de-addiction

CHEIF COMPLAINTS :

There were no specific complaints by patient but came for de-addiction

HOPI :

Patient was appareantly asymptomatie 4 years back ,then he developed

• Burning type of pain in the right and left hypochondrium,3 to 4 episodes for which he went to a local hospital and got medications(He's a chronic alcoholic), and the symptoms subsided,his last episode was the day after he got admitted here and was given pantop iv and the symptoms subsided.

• H/o weight loss approximately 20 kgs since 15 months

• 1 year back he was found to have high Sugars at a government camp at his place used OHA's for 4 months

• Then he developed complaints of Generalized weakness, polydypsia, poly urea for which he visited a private hosp at Nakrekal found to high sugars (Uncontrolled DM 2 ) He was on insulin(25 U) since then (took Insulin Irregularly) .

• Complaints of Diminution of vision since 8 months and double vision in the mornings since 7 months

• H/o light trauma 1 month back then he developed bubble like lesions associated with pain and itching for which he went to a local hospital and got some medications and pain and itching decreased but he was experiencing itching again since 29/7/22

• H/o Trauma (with mild skin abrations) 15 days back,then he developed itching over the wounds

Came to the opd and got admitted for de-addiction and was sent to GM for uncontrolled DM 2(550mg/dl)

• Complains of body pains since 3 days for which he was given tramadol

• Vomitings on 1/8/22 morning

2 episodes ,projectile type with food particles as content( early in the morning& after consuming milk) for which he's given medication and the symptoms subsided

• Burning type of pain the right and left hypochondrium and epigastric regions since 2/8/22

• Fever since 3/8/22

PAST HISTORY :

K/c/o DM 2 since 1 year

Not a K/c/o Hypertension ,asthma ,CAD, epilepsy, hypothyroidism

PRESENT HISTORY

Daily routine :

He was a labourer by occupation.

Wakes up at 6 AM

Does household work

Breakfast at 9 AM

Goes to work

Lunch at 2 PM

Returns home 6 PM

Dinner at 8 PM

Sleeps at 9 PM

" Takes Alcohol either in the morning at 10 am or 7 pm in the evening"

PERSONAL HISTORY

Diet: mixed

Appetite: normal

Bowel and bladder movements :Normal

Sleep: adequate

No known allergies

Addictions : chronic alcholic since 30 years

Chronic smoker since 30 years - 1 pack beedi/ day

FAMILY HISTORY

No significant family history

TREATMENT HISTORY

Was on glimiperide for 2 months after getting diagnosed with DM, and stopped using after that, later after 2 months He was on insulin(2.5IU) ,but was not taking insulin regularly

GENERAL EXAMINATION

•Patient is examined in a well lit room after obtaining consent

•Patient is conscious, coherent, cooperative.

Well built and well nourished.

•Mild Pallor

•Icterus,clubbing, cyanosis, koilonychia, edema are absent