A 60 year old male with fever and vomitings

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Chief complaints

A 60 year old male patient teacher by occupation came to OPD in drowsy state 2days ago fever since 3 days and vomiting since 2 days.

History of presenting illness

Patient was apparently asymptomatic 30 years back,then he had fever following which he went to local hospital where he was given an injection and since then he was feeling that something is happening to him for which one of his relatives took him to a psychiatrist and got treated and was given tablet- fluvoxetine.

H/o giddiness 26 years back for pt.went to a local hospital and got diagnosed with hypertension and was started on Tab.ATEN-AM50/5 mg OD 

During a routine health checkup 20 years back patient was diagnosed with diabetes mellitus and started using tab.GLIMI M1 OD.

H/0H/o gradual painless diminision of vision 10-15 years back for which the patient consulted an ophthalmologist and was diagnosed with cataract and underwent cataract surgery. 

Patient retired 2 years back, and stopped taking DM and HTN medication as he thought he was feeling well 

One month back , his daughter committed suicide for which he got disturbed psychologically and started excess consumption of alcohol.

He complained of itching in the scrotal region 10 days ago following which he developed swelling over the scrotum associated with pus discharge. He took medications without physician consultation.

Patient now presented with h/o fever since 2 days, low grade, intermittent and relieved on medications.associated with 20 episodes of vomitings since yesterday, non projectile, non bilious non foul smelling, with food particles as content. 

Not associated with pain abdomen, no SOB, associated with generalized weakness.

Past history

H/o DM since 20 years and is on Tab. Glimi M1 OD

H/o HTN since 25 years and is on Tab. ATEN- AM 50/5 mg OD

General examination

Patient is slightly drowsy, coherent and cooperative

Icterus present

No signs of pallor, Cyanosis, lymphadenopathy, edema

Vitals:- 

Temp:- Afebrile

BP:- 100/80 mmhg

PR:- 71 bpm

RR:- 22 cpm

Spo2- :- 99% at room air.

GRBS- High.

Systemic examination

CVS- S1, S2 heard, no murmurs

RS - Bilateral air entry present, NVBS heard.

Per abdomen:- Obese , non tender, scrotal abscess present ?fournire's gangrene

CNS:- NAD

Surgical refferal is done.

                           Before debriment

                          

After debriment

Investigations-

CBP:- Hb- 10.1 g/dl

TLC- 28,000 cells/mm3

Platelets-3.64

RFT:- 

Urea-101 mg/dl

Creatinine- 1.4 mg/dl

Na- 128 meq/litre

K+ - 4.7 mEq/L

Cl- 90 mEq /L

LFT:-

TB - 4.63

DB -0.17

AST -33

ALT- 16

ALP -333

TP- 6.0

Alb- 2.6

USG ABDOMEN AND PELVIS:-

Impression:- Grade 1 prostatomegaly

Bilateral renal calculi.

                             ECG

                  

                            Chest x ray

                 

     Acidosis

 

Provisional diagnosis-

Diabetic ketoacidosis secondary to fournier gangrene

TREATMENT:-

1) INJ. MAGNEX FORTE 1.5 gm IV/ BD

2) INJ. CLINDAMYCIN 600 mg IV TID

3) IVF NS @ 150ml/ hr

4) INJ. HAI 40 units in 39 ml NS IV @6 ml/hr >/< according to GRBS

5) INJ. NORADRENALINE 1 Amp in 49 ml NS @ 6 ml/hr >/<  to maintain MAP >/= 65mmhg

6) INJ. PAN 40 MG IV OD

7) INJ. ZOFER 4 mg IV / TID

8) INJ. THIAMINE 1 amp in 100 ml NS IV OD

9) BP/ PR/ Spo2 / GRBS monitoring every hourly

10)Strict input / output charting.