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CONTENTS
Title Page
1. Case study 1 2
2. Case study 2 7
3. Case study 3 14
4. Case study 4 18
5. Case study 5 23
6. Case study 6 28
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Case study 1

Name: Papanna

Age and sex:46 yearand male

Place: Chennagiri , Davanagere

Case history:-

Presenting complailnts:

1)Easy fatiguability since1 month

2)Increased frequency of urination in the night

History of presenting illness:

46 year old married man presented with h/0 easy fatiguabilty since 1
month. Patient also c/o aching sensation in both leg after walking for a
distance of even a half km. he also gives h/o excessive thirst , and
increased frequency of urination

No h/o any other illness in the past

Noh/o cardiac illness in the past

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Mother died recently because of massive brain hemorrhage.she was

Diabetic and hypertensive. His brother is 52 year old and is a diabetic.

Personal history: He is a cloth merchent by occupation with good

economic status. Takes alcohol occasionally and does not smoke. He
eats unlimited rice in his both lunch and dinner. No chapathi ,and eats
cooked vegitables. Breakfast varies, mostly made up of rice ond its
product.

Physical examination:

Pulse -78/min

BP - 150/90mmHg

RR – 16/min

BMI – 31 kg/m2

Patient is obese

No pallor ,jaundice, goiter

No pedal edema

All peripheral pulses are equally felt

CVS and RS within normal limits

CNS : no sensory disturbance.

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Investigations:

FBS: 180 mg%

PPBS -310 mg%

Urine sugar 2+ ketone absent

HbA1c -7.8%

Total cholesterol: 250 mg/dl , LDL: 132 mg/dl, HDL: 46mg/dl,

triglyceride : 176 mg/dl

Urea : 32 mg%

Creatinine : 0.9 mg%

Fundus: examination showed no retinopathy changes.

Treatment:

1)Education : Patient is educated regarding Diabetes , Obesity and its

complications and importance of blood sugar control. Informations
about drugs used and side effects .

2)Physical activity: Exercise: warm up for 10 min, Brisk walk for 30 min
followed by cool down phase with stretching exercice for 10 min for All
days of week. Yoga is also encouraged.
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3) Diet plan: for 1500 Kcal/ day adviced

 Early morning: 1 cup milk , tea/ coffee without sugar

 Breakfast : Milk (150 ml), 2 cup rava uppittu or2 slice bread or
Idli(2) with sambar or egg(2)
 Lunch: a) green veg salad
b)Chapathi (2 small) or 1 cup rice with 1 roti
c)1 cup tur dal
d)1 cup boiled vegitable
e)1 cup curd
 Evening snack: 1 cup tea/ coffee without sugar, ½ cup mandakki
 Dinner : vegitable Salad ,soup 1 cup,chapathi 2, 1 cup dal ,1 cup
curds
 Bed time: 150 ml of cows milk, frui 1 small banana, ½ apple

4) Medication : Tablet Metformin 500 mg twice daily started.

Tablet losartan 50 mg night time

5) Adviced to avoid alcohol consumption or limit it to < 1 drink / day

Follow up: patient was committed to the treatment and lost 2 kg in in

first month. However blood sugar was not under control at the end of
first month. (FBS- 140 , PPBS -190 mg%) . Subsequent follow up patient
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did well. At 3 month blood sugar was under control. FBS – 112 mg%
PPBS- 142 mg% .

Discussion :

Symptoms were s/o diabetes and lab investigations confirmed it.

Strong family history of DM , Obesity suggest diagnosis of type 2
diabetes. Life style modification exercise weight loss resulted in good
glycemic control. Initial treatment with only Metformin justified as it
can reduce both fasting and post prandial sugar, reduction in weight,
and does not produce hypoglycemia which is common with
sulfonilureas.
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Case study 2
Name : Siddesh

Age and sex: 33 yrs male

Address : Vidyanagar, Davanagere

Hospital number:009007

Case history:

Presenting complaints:

1)Generalised weakness, weight loss, since 1 year

2)difficulty in getting up from squatting, pain in both lower limb since 6

month

History of presenting illness:

Diagnosed to have diabetes 1 year back , when he showed to a local

doctor for the above complaints. Since then patient is taking tablet
Tripride once daily .
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Patient is not under regular follow up. Not aware of complication

related to diabetes.No diet control, poor glycemic control in last follow
up and since last 6 month he is taking Tab .Tripride twice daily.

Has difficulty in getting up from squatting, and also complains of pain in

both lower limb thigh and leg, constant, non radiating vague type.

Also c/o tinglin and numbness in both foot.

No family history of DM

No h/o thyroid disease

No h/o visual problem

No h/o Hypertension

No h/o renal or liver disease

No h/s/o peripheral vascular disease..

Clinical examination:

Conscious cooperative

Pulse 86/min, BP 90/58mm hg

RR.20/min. mild pallor,no jaundice or lymphadenopathy

BMI:17.56. has generalized wasting.

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CNS examination. HMF is normal, normal Cranial nerves .

Wastig prominent in proximal muscle of both lower limb wasting of

quadriceps present. DTR diminished in both knee and ankle. power 3/5
in both extensor of hip 4/5 in flexors abductors. 4/5 in flex and ext of
knee. Loss of pain temperature touch up to 75% up to knee.Vibration
sense lost up to knee.upper limbs are normal.

CVS & RS are normal

Normal abdominal finding

Fundus ; retinopathy NPDR

Investigation:

RBS – 485mg

HbA1c- 10.5%

Hb -9.8gm% microcytic hypochromic blood picture

Urea- 28 mg/dl

Creatinine -1.1 mg/dl

Urine albumin +, ketone absent,

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ABG; Normal

LFT normal

Vit b12.normal

Lipid profile- Total cholesterol-150, T.gl 242 mg/dl,LDL- 64mg/dl, HDL-

37mg/dl

ECG-Normal

Diagnosis:

Type 2 diabetes mellitus – uncontrolled

Peripheral neuropathy with diabetic Amyotrophy

Diabetic retinopathy.

Diabetic nephropathy

Treatment :

Patients blood sugar was initially controlled by i.v.insulin infusion. He

was educated regarding diabetes and its complications. Oral
hypoglycemic were stopped.

Diet ; 2500 kcal diet. Adviced to take complex sugars.

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Insulin ; inj Recosuline M 30/70 (40iu) 25- 0 – 15,

B complex vitamin

Educated regarding foot care .

Advice regarding storage of iunsulin, technique of taking insulin,

Importance of self monitoring of blood sugar given.

Patient came to opd after 1 week. There was general wellbeing, FBS
138mg/dl PPBS- PPBS 198 mg /dl. Insulin adjusted to 28 – 0 – 15.

1month after his FBS 112mg, PPBS 158mg/dl. Weigt increased by 1.5
kg. weakness not deteriorated.

Discussion :

Possibility of type1 DM not ruled out.Since patient is young , with no

family h/o diabetes , and blood sugar initially responded to OHA
became dependent on Insulin with in span of 1 year of diagnosis of DM
s/o possible LADA in this patient. Since c-peptide level presence of
antibody level would have helped in diagnosis not done in this patient
due to lack of facility. Amyotropy present in this case with generalized
wasting was special feature recognized in this patient. Patient
presenting for the first time with features of neuropathy and
amyotropy at the time of diagnosis of DM was unusual.
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Fig : patient with generalized wasting and wasting of quadriceps

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Fig: wasting of proximal muscles of lower limb

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Case study 3
Name : Kantesh
Age and sex: 16 yrs Male
Place : Jagaluru, Davanagere.
Hospital number: 008963
Case history :
Presenting complaints:
1)Fever and cough since 8 days

2)Altered sensorium and hurried breathing since 4 hour

History of presenting complaints:

16 yr old boy brought to casualty with history of fever and cough of 8
days duration.had taken treatment from a local doctor for the above
complaints fever subsided after 2 days, but cough persisted. Since
afternoon boy became drowsy ,and breathing fast.Gives h/o recent loss
of weight .

Father is diabetic since 6 yr on OHA

Physical examination :

Patient was drowsy, disoriented

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Tachypnic at rest,

Pulse -124/min

BP - 90/60 mmHg

RR - 32/min

Temp – 102 F

Ht 148 cm wt- 45 kg

Pallor ,jaundice absent

Poorly nourished

Severely dehydrated,

Respiratory system : dullness and bronchial breathing in left

infrascapular and infraaxillary area.

Other systems were normal

Investigation:
RBS – 432 mg/dl

Urine ketones – positive

Hb 13.6gm%

Total Leucocyte-18,200 ,DC N/L /M/E,80/12/7/1

pH ; 7.10

N+ 138 , K+ 4.3 Meq

LFT. Normal
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Blood culture was sent.

Chest X ray; non homogenous opacity left lower zone.

Diagnosis :
Type 1 diabetes mellitus( first time detected)

Left lower lobe pneumonic consolidation

Diabetic ketoacidosis

Treatment :
Patient was shifted to intensive care unit.nasogastric tube and urinry
catheterization was done.

Fluid correction was given. Initially isotonic saline at the rate of 20ml/kg
given. Dose was repeated in next hour. As blood pressure improved
maintainance fluid started with half normal saline.changed to dextrose
5% once sugar was 130 – 180mg%

Electrolyte: Potassium correction given with 40 meq in each litre of i.v

fluid. Bicarbonate correction was not given

Insulin: I.V bolus Regular insulin 8 unit given followed by infusion rate
of 0.1 U /kg/h

I.V antibiotics started with Inj.Ceftriaxone 1gm twice daily. Inj

Azithromycin 500 mg.
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Patient improved next morning became conscious oriented and allowed

to take orally. Discharged after 8 days .

During this period patient and parents educated regarding th disease ,

complication and need of life long Insulin therapy. Patient was
discharged with Inj. H.Mixtard s/c 20 – 0 -10 .and 14 days of antibiotic
course.

Discussion :

This patient is type 1 diabetes because he is young , presented first

time with ketoacidosis. Family h/o DM is probably coincidental. This
partient had precipitating factor in the form of pneumonia. Severe
dehydration was effectively managed with proper i.v fluid.
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Case study 4

Name : Pushpalatha

Age and sex: 27 yrs female

Place: Davanagere

Hospital number: 20986

Case history:

History of present illness:

This patient was refered by a local obstetrician.27 year lady primy

gravidae had come for antenatal check up with h/o 6 month
amenorrhea.

No h/o diabetes in the past.

Mother and father both are type 2 diabetic.

Patient is vegetarian .No habits.

Physical examination:
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Pulse – 88/min.

BP -130/80 mmHg

Wt- 58 kgs

HT -158 cm

BMI -23.29 kg /m2

No pallor no jaundice.

CVS ; normal

RS : normal

Uterine size corresponds to gestagenal age.

Investigations:
Hb – 12 gm%

HbsAg non reactive

HIV – non reactive.
TSH - normal

Obstetric scan. live fetus 23 week 4 days

75 gm Oral glucose tolerance test

 Fasting blood sugar : 98 mg / dl: nil urine sugar

 1 hour blood sugar 200 mg/ dl :trace urine sugar
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 2 hour blood sugar 168 mg/dl : urine sugar ni

HbA1c-6.8%

Diagnosis :

Gestational diabetes mellitus

Treatment :

1)Diet adviced . Adviced to have 2100kcal diet plan.adviced to monitor

weight gain.

 Early Morning: A glass of milk (250 ml approx.) without sugar/ a

cup of tea with two Marie biscuits.
 Breakfast (between 8 AM – 9 AM): A cup of milk (approx. 150 ml)
without sugar and two whole wheat bread slices with 30 gm
cottage cheese (paneer) or one boiled egg / two vegetable stuffed
chapattis with a bowl of curd / two small dosas or four idlis
without chutney. Use only 1 tsp of oil for cooking.
 Mid Morning (11 AM): One medium-sized fruit (150 gm approx.)
such as guava, pear, plum, apple, sweet lime (mausambi), peach,
or one small bowl of fully ripe papaya.
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 Lunch (between 1 PM to 1:30 PM): Start with one quarter plate of

salad (cucumber, tomato, carrot, radish), one small bowl of
seasonal vegetable, one small bowl of dal, about 150 ml (1 cup)
curd, three chapattis / two chapattis and 3/4th bowl of rice. Use
only 2 tsp of oil for cooking.
 Evening (4 PM): A cup of milk without sugar / a cup of tea with
two Marie biscuits.
 Evening Snack (6 PM): A small bowl of sprouts with a glass of
fresh lime juice (without sugar).
 Dinner (8 PM – 8:30 PM): Same as lunch. But try to have other
variety of what you had in lunch, for example, you can take matar
paneer, mixed vegetable, nutri-nuggets curry, whole moong dal,
masoor daal, or black chick pea gravy, green beans and carrots
etc. Avoid curd and rice at night. Use only 2 tsp of oil for cooking.
 Bed Time: 1 glass milk (250 ml approx.)/ 1 cup milk (150 ml
approx.) with one small sized fruit (150 gm approx.)

2) Inj. Recosulin M 30/70 s/c pre breakfast and dinner and additional
insulin dosage is adjusted with Regular insulin based on pre breakfast
and pre dinner glucose values.

3)Adviced to self monitor blood sugar with glucometer.

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Patient was appropriately managed to have safe delivery and normal

weight baby.

Discussion :

This patient has two value higer then the normal range in WHO guided
OGT test. Since prior history of her glycemic state not known and it is
diagnosed at 24 week of gestation and also detected for the first time
during pregnancy , therefore diagnosis of gestationl diabetes was made
in this case. Patient is also a high risk for gestational diabetes since she
has strong family h/o diabetes and age > 25 years. Also in this case GTT
should have been much earlier as she had risk factor fo gestational
diabetes mellitus.

Total calorie requirement in this case was 1740kcal + additional 300

Kcal was added as patient was in later half of pregnancy.

Recommended weight gain in this patient was 11.4 to 15.9 kg during

pregnancy. Patient gained ideal weight.
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Case study 5

Name : Lakshmamma
Age and sex : 82 year, female
Place : harihar , Davanagere
Case history:
Presenting complaints:
Sudden onset of dyspnea since 4hr

History of present illness:

Known diabetic for past 15 years, detected in a health camp , presented
with sudden onset of breathlessness since morning.there was no h/o
chest pain. Patient was initially on oral hypoglycemic agent details of
which is not available. Since six month patient is on Inj Wosulin 25/75
20- 0 – 10 s/c and metformin .

Patient is hypertensive detected 6 month back and taking tab Aten 50

mg once daily .

On irregular follow up under ESI doctor. Aware of diabetic

complication, no self monitoring of blood glucose.

Insulin not stored in specific temperature as she don’t have refrigerator

at home.
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c/o decreased vision both the eye.Undergone b/l cateract operation 3

year back

No h/o chronic lung disease

No h/o sensory disturbance

No h/o renal failure

No h/o liver failure.

No h/o Coronary artery disease or peripheral vascular disease.

Physical examination:
Conscious and oriented tachypnic at rest

PR118/ min

BP- 150/ 110 mmHg

RR 36/ min

No pallor no jaundice no lympadenopathy

No pedal oedema, neck vein engorged

All peripheral pulses well felt.

BMI – 27.6, Wt-63kg Ht 151 cm

Respiratory system : b/l basal crepitation present.

CNS; impaired vibration sense in left foot

Fundus : moderate NPDR.

Investigation:
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RBS- 465 mg%

Urea - 35 mg/dl

Creatinine - 1 mg /dl

Na+ 131.6 k+ 4.35 meq/l

WBC – 16,150

Hb – 11.5gm%

Urine ketone absent, albumin +,

ECG- LVH and T. wave inversion in lateral leads

2DEcho;CAD, LVEF -37 %, dilated LV, mild MR, Trivial TR,moderate LV

systolic dysfunction.

Diagnosis :
Type 2 diabetes (uncontrolled)

Acute left ventricular failure secondary to Coronary Artery Disease.

Hypertension

Diabetic retinopathy (NPDR)

?Diabetic nephropathy

Diabetic peripheral neuropathy.

Treatment :
Admitted in ICU. oxygen was given .Tab Ecosprin 325 mg given
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.Patient was given propped up position and started on intravenous

Inj.Frusamide.

Insulin infusion was started. Blood glucose was monitored hourly and
insulin is titrated accordingly.

Following drugs were also started.

Inj.LMWX 0.4 ml s/c twice daily

Tab . Atorvastatin 40 mg stat and 0 – 0- 1

Tab . Clopidrogel with Aspirin75 mg 0 -1 - 0

Tab . Ramipril 5 mg 0 - 0 - 1

Betaloc 12.5 mg twice daily.

Patient improved and discharged after 1 week. Insulin was changed to

Hum .Insulin 30/70 and discharged with 16 – 0 – 8 units and
tab.metformin . Diet adviced. Adviced to undergo angiography. Patients
son promised to buy a refrigerator to store insulin.

Discussion:
Patient was diabetic and was on insulin but blood sugar was not under
control. Probable reason being

1)Potency of insulin must have been lost as it was not stored properly
in such a hot climate .

2)CAD with LVF is an acute stressful condition leading to hyperglycemia.

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Patient was treated like an acute coronary syndrome because she was
not known case of ischemic heart disease and many times patients of
diabetic present atypically without Angina.

ACE inhibitors added to control Hypertension, prevent LV remodeling,

prevent Albuminuria in this patient.
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Case study 6
Name : Lakshmidevi
Age and sex: 51 year , Female
Place : Harappanahalli, Davanagere
Hospital number: 009276
Case history:
Presenting complaints:
Ulcer over right foot 15 days

Generalized weakness since 15 days

History of presenting illness:

A known diabetic since 1 year presented with h/o small bleb over
dorsum of right foot 15 days back, initially very small swelling of peanut
size gradually increased to a size of 4x4 cm size.5 days back it ruptured
to leave a ulcer behind. Patient showed to an ayurvedic doctor in her
place . ulcer did not heal. There was no h/o trauma. h/o mild fever
present.

Patient is taking T. Metformin 1000mg /day. Under strict diet control.

Aware of diabetic complications. No h/o intake of any medication of
alternative science if medicine.
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According to patient she is under regular follow up, blood sugar was
under control.

Father is known diabetic and doing well.

H/o decreased vision since 6 month > RT eye

No h/o of renal or liver disease.

H/o tingling sensation in both feet since 3 month

No h/o ischemic heart disease

No h/o claudication pain.

No h/o stroke.

Physical examination:
Conscious .oriented

Pulse 82/min

BP – 150/86 mmHg

RR -14/min

BMI – 21.7 kg/m2

Mild pallor, no jaundice

All pulse well felt.

Ankle / brachial pressure ratio 1.1

CVS—Normal finding

RS – normal
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CNS – Decresed vibration in both the foot. Pain temp decresed 50%
both foot.

FUNDUS: Moderate NPDR with Rt LSME

Local examination:

Ulcer of 1x2 cm ,healthy margin, floor covered with slough, skin

surrounding ulcer inflamed with edema .

Fig 2. Diabetic foot.

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Investigation :
 FBS --154 mg/dl
 PPBS – 210 mg /dl
 Urine micro albuminuria+ ketone absent.
 Hb – 10.2gm%
 Total leuk count- 13,200
 Total cholesterol- 256mg%
 LDL – 156 mg%
 HDL -35
 Urea – 23 mg/dl
 Creatinine – 0.9 mg/dl
 SGOT and SGPT – Normal limit
 HIV and HbSAg – Non reactive

Diagnosis :
Type 2 diabetes mellitus

Hypertension

Diabetic foot

Diabetic peripheral neuropathy

Moderate NPDR

Treatment :
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 Ulcer treatment was adviced. Daily dressing of foot after

removing slough was done. Systemic antibiotics given amperically.
 Foot care:
o advice regarding foot care given, foot protection ulcer
prevention by wearing padded socks.
o Daily foot inspection, checking shoes before wearing for
the presence of anyobjects nails etc.
o Avoiding soking in water
o Emmolient cream application prevention of crack and
infection.
 Exercice & importance of blood sugar comtrol emphasized.
 Following medications were started.
o Inj . Recosulin M 30/70 s/c 10 – 0 – 6
o Tab.metformin 500mg 1 - 0-1
o Tab .atorvastatin 10mg 0 – 0 -1
o Tab . Telmisartan 40 mg. 1 -0 -0
o B- complex vitamin daily.
 Ophthalmologist advised laser therapy once she becomes stable.

Ulcer healed in 8 days .insulin requirement has came down drastically.

Insulin was stopped on 8 th day. Patient was discharged with T.

Metformin.

Discussion : She is type2 diabetic with family h/o diabetes. In this

case trevial trauma is probable cause of diabetic foot initially unnoticed
by patient. There was no peripheral vascular disease. Once infection
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was under control sugar came down to normal. So source control is

important in controlling sugar. It is always adviced to relace OHA s with
Insulin because sugar can be better controlled with insulin and healing
delays in the presence of hyperglycemia. ARB started to control micro
albuminuria and hypertension.proper foot care can prevent diabetic
foot on also economic burden on the patient.