GENERAL MEDICINE - A 20 YEAR OLD MALE

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A 20 yr old male who is resident of nalgonda came to OPD on 18th of january. 

CHIEF COMPLAINT :-

A 20 yr old male came to opd with chief complaint of :

-Loss of weight since 1 month 

-Excessive drinking of water since 6 months. 

HISTORY OF PRESENT ILLNESS :-

Patient was apparently asymptomatic 1 month back. Then he noticed gradual loss of weight nearly 7 kgs (73 kgs to 67 kgs) in a span of 1 month.

He had h/o polydypsia since 6 months(drinks 7 to 8 liters of water per day).He had H/0 polyuria.

He had h/o tingling sensation of fingers of lower limbs.He had no h/o fever,fatigue,giddiness and burning micturition.

HISTORY OF PAST ILLNESS :-

He had history of covid 2 years back and had a h/o acute fulminant hepatic failure. 

He had h/o post covid Multisystem inflammatory syndrome. 

He had h/o denovo type I DM 2 years back. 

No h/oHtn, thyroid, TB, epilepsy, asthma. 

PERSONAL HISTORY :-

Diet - Mixed
Appetite - normal
Bowel and bladder movements - regular
Sleep - Adequate
Addictions - Regular alcohol
Allergies - None

FAMILY HISTORY :-
No relevant family history. 

PHYSICAL EXAMINATION :-
General Examination:-

Patient is conscious , coherent , cooperative and well oriented to time , place and person. 
He is moderately built and well nourished. 
No signs of pallor , icterus , cyanosis , clubbing , oedema , lymphadenopathy. 

Vitals:-
Temperature : Afebrile
BP : 130/80 mm HG 
Pulse rate : 76 bpm
Respiratory rate : 16 cycles/min
Grbs:160 mg/dl  
CLINICAL IMAGES :-

SYSTEMIC EXAMINATION :-

CVS - S1 S2 heard,no murmurs present.

Respiratory system - Bilateral Air entry is normal. 
Normal vesicular breath sounds heard. 

Abdomen - soft , non tender 

CNS - no focal neurological deficits. 

INVESTIGATIONS :-

                 18/01/23               19/01/23

Plbs :-     403mg/dl                403mg/dl
Fbs :-       222mg/dl                118mg/dl
Serum 
creatinine:- 0.8mg/dl              0.8mg/dl
HbA1c :- 7.5%                          7.5%
Albumin :- 4.5                          Nil

RFT :-
Serum uric acid - 2.7
Serum electrolytes -
           Sodium - 140
           Potassium - 50
           Chloride - 98
LFT :-
Sgot - 13
Sgpt - 12
ALP - 234
TP - 7.0
Complete Urine Examination :-
Color - pale yellow
Appearance - clear
Reaction - acidic
Specific gravity - 1.010
Bile pigments - Nil
 
 ECG :-
  PLBS :-
FBS :-Serum Creatinine :-Gycated Hemoglobin :-APTT :-Liver function test :-Complete urine examination :-Ultrasound :-Chest X ray :-
DIAGNOSIS :-
     Uncontrolled Type 1 diabetes mellitus
TREATMENT :-
Inj HAI SC/TID
Inj NPH SC/BD





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