A 49 year old male with giddiness

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A 49 Year old male, autodriver by occupation , came to casualty on 24th June 2023 with chief  complaints of giddiness since 5 days 

Vomiting since 1 day

History of present illness

Patient was apparently asymptomatic 1 month back the he developed headache which is on right side it is continuous usually relieved on taking cool drink .He had 3 to 4 episodes of head ache for which he went to a private hospital .MRl shows lesion on lateral side of medulla

After 20 days of taking medication he developed giddiness insidious in onset gradually progressive.

 C/o Vomitings 4-5 episodes, watery, non-projectile, bilious with food particles as content. Not Blood tinged. Relieved with medications.

 C/o Loose stools: 4-5 episodes, watery, non blood stained, non-mucoid, non- foul smelling

No C/o Fever, pain abdomen, decreased urinary output, pedal edema.

Past history.

Patient is a known case of  DM II since 13 years and is on medication. Now using GLIMI-M4 Forte PO/OD(morning) and GLIMI-M3 Forte PO/OD(Night)

K/C/O HTN since 1 week

The patient was operated for haemorrhoids 20 years back

 Not a known case of CAD, Bronchial asthma, Epilepsy, TB.

PERSONAL HISTORY

DIET - Mixed

APPETITE- Decreased since 5 days

SLEEP - Adequate

BOWEL AND BLADDER- Regular

ADDICTIONS - Binge alcoholic since 13 years.Stopped consumption 6 years back- habituated to soft drinks

Chewing tobacco since 20 years.

No known allergies.

Daily routine

The patient is a Farmer and Autodriver

4AM: Wakes up and Freshens. Goes to look after his farms and comes back at 7AM

8AM: Drinks Tea

9AM: He eats Rice( Daily one cup) with soft drinks (Consumes soft drinks throughout the day whenever he is thirsty)

10AM- 1PM: Goes for driving Auto

1PM: Eats Lunch- Rice with dal 

2PM: Takes an afternoon nap and wakes up at 4PM

4PM: Goes for driving Auto

6:30: Tea and soft drink

8PM: Dinner

10PM: The patient goes to bed by 10PM

Family history

Not significant.

GENERAL EXAMINATION

Patient was examined in a well lit room after taking informed consent.

He is conscious, coherent and cooperative; moderately built and well nourished.

No icterus, clubbing, cyanosis, lymphadenopathy, edema.

VITALS on 24/06/2023

1. BLOOD PRESSURE: 170/100 mmHg

2. PULSE PRESSURE: 60 Bpm

3. RESPIRATORY RATE: 14cpm

4. TEMPERATURE: Aferbile

5. SpO2: 98% on Room air

6. GRBS: 428mg/dl 

SYSTEMIC EXAMINATION

1. RESPIRATORY SYSTEM : B/L Air entry Present, Normal vesicular breath sound+


2. CARDIOVASCULAR SYSTEM: S1, S2 heard, no murmurs.



3. ABDOMINAL EXAMINATION : Soft, Non- Tender

4. CNS - No Focal neurological deficits

INVESTIGATIONS 

                       

                                                    

PROVISIONAL DIAGNOSIS

Diabetic Ketosis secondary to ? Acute Gastroenteritis

TREATMENT

1. Intravenous fluids normal saline @100ml/hr

2. Injection Human actrapid insulin I.V infusion (1ml +39ml NS) @6ml/hr

3. Inj. PAN 40mg IV/OD 

4. Inj. BUSCOPAN IM/ SOS

5. Tab. TELMA 40mg PO/ OD

6. Monitor GRBS Hourly

7. Strict input output charting