Type 2 Diabetes Melitus with uncontrolled sugars

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Case presentation:

A 60 year old male patient who is a resident of Nalgonda and farmer by occupation came to the medicine OPD for regular follow up for Type 2 DM and complains of polyuria and increased sweating since 6months

History of present illness :

Patient was apparently asymptomatic 6months back then he developed increased urine output and sweating since 6 months, tingling sensation of both upper limbs since 6months, blurring of vision since 6months

No h/o polydipsia, polyphagia

No h/o pain abdomen, vomitings,giddiness and decreased appetite 

No h/o fever, cough, chest pain,SOB

Past history :

K/c/o T2DM since 1 year on irregular medications

Not a k/c/o HTN, TB, Epilepsy, Asthma, CAD, thyroid abnormalities 

Personal history : 

diet is mixed with normal appetite and adequate sleep, increased frequency of micturition

Chronic alcoholic with daily consumption of 3-4 litres of Toddy since 40 years and occasional whisky consumption since 40years(90ml)

He consumes 1-2beedis daily since 40years 

General examination :

Patient is conscious, coherent and cooperative, moderately built and well nourished. 

Patient is afebrile, 

pulse-80 bpm with regular rate, rhythm and volume. 

Bp- 120/80mmHg recorded in right arm sitting position 

RR-24cpm

Systemic examination :

CVS 

S1,S2 heard, no murmurs 

RS

BAE present, normal vehicular breath sounds heard, no additional sounds were heard. 

Per Abdomen:

All quadrants moving equally with respiration, no scars, sinuses and engorged veins

On palpation abdomen is soft, non- tender  and no organomegaly

CNS: 

GCS 15/15

NAD

Investigations at admission 

Day 1

ABG

ECG                                                       

Day2:

Day 4.                                                 

Diagnosis:

   Type 2 Diabetes mellitus with uncontrolled sugars 

Treatment:

1) IVF - NS @ 75ml/hr

2) Inj human actrapid insulin s/c acc to sliding scale. 

3) Tab metformin 500mg BD

4) Inj optineuron 1amp in 100ml NS IV BD

5) I/O charting

6) BP,  PR,  sPO2 monitoring 

7) GRBS monitoring 2nd hourly

8)Tab Sporolac DS TID

9) ORS 1sachet in 1litre water(200ml after each stool)