36 year old with pain in left lower rib region

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A 36 year old, M.Sc Biochemistry teacher by occupation, came with complaints of pain in left lower rib since 1 week and complaints of vomittings since 3 days. 

History of presenting illness: 

Patient was apparently asymptomatic 7 years ago when he had an episode of giddiness and fall and went to the hospital where he was diagnosed with Diabetes mellitus and was started on OHAs. Patient used to go for regular check ups, got FBS, PLBS, which were under control on Metformin. 

He later shifted to GLIMI M1 and now GLIMI MV2 2-3 months ago. However, he says he hasn’t been regular with his medication since one week. 

3 years ago, patient had binged on alcohol, didn’t consume any food and developed pain abdomen and was diagnosed with Acute pancreatitis. He received treatment for 15 days at an outside hospital. 

3 years ago patient had a ? Callus formation/ thickened part on plantar aspect of left foot, patient himself used to cut the thickened part with a blade, which one year ago turned into an ulcer, for which he underwent debridement 1 year ago. He does his own dressing by using spirit to clean and the area and then puts iodine and cotton on it, every alternate day. 

He quit his job 2 years ago and is only staying at home since then, but occasionally teaches as a guest lecturer.

2 years ago he attempted suicide by consuming OP poison and was admitted and treated outside for it. 

1 and a half years ago, he again binge on alcohol and developed pain abdomen but it was not diagnosed as another episode of acute pancreatitis. 

Since 1 year, he is experiencing burning sensation in his feet, tingling sensation from his foot to his calf. 

He has pedal edema till in ankle in his left foot, which is of pitting type, and seen only at the end of the day. 

5 days ago, he fell from his bike and since then is experiencing pain in his left lower rib area. Tenderness present. 

Now, since 3 days he again binged on alcohol and stopped taking OHAs and stopped consuming food. 

He also has complaints of vomittings since 3 days which were non projectile, non bilious and had food particles as content.  He had one episode of blood in vomitus 3 days back and never again. 

He reports intolerance on drinking water as well, feels nauseous as soon as he consumes water. 

Past history: 

He was diagnosed with Diabetes mellitus 7 years back and was started on Metformin initially, then on Tab, GLIMI MV1 and now since 2-3 months is using Tab. GLIMI MV2. 

Vitals on admission: 

Temp: 98°F

PR: 104bpm

RR: 18 cpm

BP: 120/80 mm hg

SpO2: 98% on RA 

GRBS: High (>400mg%)

On examination, 

Mild pallor present. 

No icterus, cyanosis, clubbing, lymphadenopathy. 

Pedal edema present upto ankle in Left foot. 

CVS: S1 S2 present 

RS: BAE + 

CNS: 

HMF- intact, conscious 

Cranial nerves: normal 

Motor system:

 Tone:   R.     L

UL.     N.      N 

LL.     N.      N 

Power:  R.     L

UL.       5/5.  5/5

LL.       5/5.  5/5

 Reflexes:    R.     L

B.               ++.     ++

T.                +.        + 

S.               ++     ++

K.               ++    ++

A.               +.     +

Babinski.   Negative 

Sensory system:

 2 point discrimination: 

UL.    +.     +

LL    Absent in toes 

Vibration: Medial malleolus.   4.8s    4.2s

                  Knee                       5.7.    5.3

                  Elbow.                     7.89. 8.1

Proprioception: 

UL   +.      +

LL.  Absent in Greater toe and second toe in both left and right LL 

Investigations:

15/3/22

S. Lipase: 48 IU/L

S. Amylase: 74 IU/L

Urine for ketone bodies: negative 

ABG: 

LFT: 

TB: 1.08

DB: 0.24

AST: 18

ALT: 10

Alk P: 242

TP: 7.3

Alb: 4

A/G: 1.23

ABG: 

USG ABD

Chest X ray AP view: 

ECG: 

Serum creatinine: 1.0

Serum urea: 15

Hemogram: 

Hb: 10.5

TLC: 5,400

N:65

L: 28

PLT: 2.30

 

Na: 138

K: 4.1

Cl: 99

Diagnosis: 

Uncontrolled sugars 

Diabetic ulcer on left lower limb 

Diabetic neuropathy

Treatment: 

1. Inj. HAI 6U given STAT

2. Inj. NS . 2 bolus given 

3. Inj. PANTOP 40mg IV OD

4. Tab. PREGABALIN 75mg OD H/S

5. Inj. TRAMADOL 1 amp in 100ml NS IV

6. Inj. ZOFER 4mg IV TID

7. Inj. THIAMINE 100mg + 100ml NS IV BD 

8. Tab. ULTRACET 1/2 PO/ QID 

9. Inj. HAI 10 units—x—6 units  pre meal and Inj. NPH 6 units BD

https://caseopinionsbyrollno156.blogspot.com/2022/03/36-year-old-with-pain-in-left-lower-rib.html

NEW ADMISSION 

16/3/22

AMC BED 1 

S: Complaints of pain in left lower rib region

O: 

Temperature: 98.6°F

BP: 130/100 mmHg

PR: 102 bpm 

GRBS: 144mg/dl

CVS: S1 S2 +, 

Not thrills or murmurs heard.

RS: BAE+, normal vesicular breath sounds heard 

CNS:

Motor system:

 Tone:   R.     L

UL.     N.      N 

LL.     N.      N 

Power:  R.     L

UL.       5/5.  5/5

LL.       5/5.  5/5

 Reflexes:    R.     L

B.               ++.     ++

T.                +.        + 

S.               ++     ++

K.               ++    ++

A.               +.     +

Babinski.   Negative 

Sensory system:

Sensory system:

 2 point discrimination: 

UL.    +.     +

LL    Absent in toes 

Vibration: 

Medial malleolus.4.8 4.2s

Knee                       5.7 5.3.                     Elbow.                    7.89. 8.1

Proprioception: 

UL   +.      +

LL.  Absent in Greater toe and second toe in both left and right LL 

P/A: soft, tenderness present in left hypochondrium. 

LFT: 

TB: 1.08

DB: 0.24

AlkP: 242

S. Lipase: 48

S. Amylase: 74

RBS: 370 mg/dl

UKB: Negative 

Blood urea: 15

Serum creatinine: 1.0

Na: 138

K: 4.1

Cl: 99

Hb: 10.8

TLC: 5,400

N: 65

Plt: 2.3 lakh

GRBS Charting: 

2AM (16/3/22): 101mg/dl

6AM (16/3/22): 97 mg/dl

8 AM ( 16/3/22): 144 mg/dl

A: Uncontrolled sugars 

Diabetic ulcer on left foot 

RTA with ?Left lower rib fracture

Diabetic neuropathy

P: 

1. Inj. PANTOP 40mg IV OD

2. Tab. PREGABALIN 75mg OD H/S

3. Inj. TRAMADOL 1 amp in 100ml NS IV

4. Inj. ZOFER 4mg IV TID

5. Inj. THIAMINE 100mg + 100ml NS IV BD 

6. Tab. ULTRACET 1/2 PO/ QID 

7. Inj. HAI 10 units—-x—-6 units TID pre meal and Inj. NPH 6 units BD

17/3/22

https://caseopinionsbyrollno156.blogspot.com/2022/03/36-year-old-with-pain-in-left-lower-rib.html

S: Complaints of pain in left lower rib region

O: 

Temperature: 98.6°F

BP: 130/100 mmHg

PR: 98 bpm 

GRBS: 305mg/dl

CVS: S1 S2 +

RS: BAE+

CNS:

Motor system:

 Tone:   R.     L

UL.     N.      N 

LL.     N.      N 

Power:  R.     L

UL.       5/5.  5/5

LL.       5/5.  5/5

 Reflexes:    R.     L

B.               ++.     ++

T.                +.        + 

S.               ++     ++

K.               ++    ++

A.               +.     +

Babinski.   Negative 

Sensory system:

Sensory system:

 2 point discrimination: 

UL.    +.     +

LL    Absent in toes 

Vibration: 

Medial malleolus.4.8 4.2s

Knee                       5.7 5.3.                     Elbow.                    7.89. 8.1

Proprioception: 

UL   +.      +

LL.  Absent in Greater toe and second toe in both left and right LL 

P/A: soft, tenderness present in left hypochondrium. 

FBS(16/3):107 mg/dl

PLBS(16/3): 383mg/dl

Total cholesterol: 217mg/dl

TAG: 438

HDL: 55

LDL: 122

A: Uncontrolled sugars 

Diabetic ulcer on left foot 

Diabetic neuropathy

RTA with left 11th rib displaced fracture 

P: 

1. Inj. PANTOP 40mg IV OD

2. Tab. PREGABALIN 75mg OD H/S

3. Inj. TRAMADOL 1 amp in 100ml NS IV

4. Inj. ZOFER 4mg IV TID

5. Inj. THIAMINE 100mg + 100ml NS IV BD 

6. Tab. ULTRACET 1/2 PO/ QID 

7. Tab. GLIMY M2 PO/BD