Endocrinology case series

Presenters: Mubiru Dennis MMED 1, Sagaala Kabanda

Discussion:
Date: 5th/September/2023
Presenting complaint

• ME a 53 years Male from magoma, kagadi ,a Mukonjo and

Christian NOK is PT a brother.

• Admitted on 28th/08/2023, (2:35am) Referred from Magoma hospital with

• Reduced urine output x3/52

• Worsening lower foot ulcers x1/12
• On and off abdominal pain x 2/12
• Worsening Constipation x3/12
 History of presenting complaint
• ME , 53yr/M is a Diabetic patient x17 years, poorly controlled HTN x 6
years whose was initially on herbal medicines with poor glycemic
control, later switched to metiform and glibenclamide with poor
adherence .

• was well till 3/12 prior to admission when he developed progressively

worsening, generalised abdominal pain dull in nature and on , off .

•
History of presenting complaint

• bloating nausea and vomiting especially minutes after meals .This was also
associated with episodes constipation that was relieved by laxatives initially
but currently has becoming non responsive.

• 1/12 prior to admission he developed a progressive reduction in urine output

which worsened the nausea and vomiting.it was associated with generalised
body swelling , reduced energy and facial puffiness and muscle pains.
• 3/52 hx of a painful left foot ulcer ( big toe)and he was applying traditional
meds, Its was associated with swelling of the foot, numbess,pricks and loss
of sensation (fine touch),

• He was managed for Gastritis and partial intestinal obstruction magoma

health facility with no improvement then referred to Mulago hospital for
further management and specialist care.
Review of Systems

• CNS; he reported history of blurred vision in both left and right eye x3
months. He suddenly started facing challenges remembering and thinking
• R/S : reported history of dry cough for 5 days,

• Cvs ;No, history chest pain,palpitation,DIB

• G/s ,Report history of erectile dysfunction x 4 months and occasionally

uses medicine to improve
Medical history

• Had history of poorly controlled hypertension but on atenolol and

captopril (poor adherence)

• Diabetic patient with history of herbal medicine use,then metiformin

and glibenclamide and currently on mixtard insulin 10IU od.
• Reported history of occasional use of penegra 100mg to improve
erectile dysfunction
Social history

• He is Christian.

• His married two wives with ten children all alive.

• He is a business man.

• No history of smoking or alcohol use.

Summary

• ME, 53yr/ M, a Diabetic with poor glycemic control and poor adherence who was herbs
later metformin 1g and glibenclamide 5mg currently on mixtard 10IU od.,

• who presented with 1/12 hx of reduced urine out put associated nausea ,vomiting , a
stable generalized body swelling ,face, abdomen , the lower limbs

• 3/12 hx of on and off dull generalized abdominal pain, bloating and worsening hx of
constipation but relieved by laxatives initially.

• He also had 1/12 history of a painful (burning, pricking) worsening left foot ulcer

• . 3/12 hx of blurred vision.

Differential Diagnosis In view of

1.Chronic kidney disease(ESRD) • reduced urine output,

?uraemia/hyperkalemia
2. DM complicated with
diabetic foot
gastro paresis
Erectile dysfunction
3. Poorly controlled Blood pressure
• facial puffiness,
• body swelling, nausea and vomiting
Chronic foot ulcer,
constipation,
Bloating
nausea
Hx of poorly controlled sugars
Hx of HTN with poor adherence

4.DM/ HTN retinopathy Loss of vision

Chronic osteomyelitis Chronic foot ulcer

ANY QUESTION ?
On examination
• General examination;

Middle age patient, sick looking lying in bed ,a febrile temp 36.7 oC, obvious facial puffiness,
mild pallor, no dehydration, no jaundice ,no palpable lymph nodes ,no neck swellings, has
unilateral non tender pitting oedema grade 1 Rt lower foot,

Local examination

Right ulcerated, black stained big toe with hyper pigmented dry foot,tinea pedis .Involuntary
movement of both lower limbs. Wasted lower limb muscles,diskeratotic nails , , warm, non
tender with present dorsalis pedis and reduced sensory response to fine and course touch no
the right foot. Left lower limb and hands are normal ,no harmer toes
• Gastrointestinal system examination:

• Moderate distenstion,moving with respiration no scars or peristaltic

movements, mild epigastric tenderness ,No masses,tympanic,reduced
bowel sounds,.

• Per rectal ,normal spinter tone ,hard stool ,prostate not palpable, no blood
on the examining finger

• Cardiovascular system examination: BP - 152/101mmHg, 88 bpm pulse

was regularly regular and full volume. Heart sounds one and two heard and
normal.
• Respiratory system examination: RR- 23bpm, SpO2-99% on RA, No chest deformities,
chest was symmetrical, Trachea was centrally placed, Expiratory rhonchi Normal air
entry.

• Nervous system exam: sleepy pupil dilated, none reactive to light with right sided
cataract , GCS 15/15, fine tremors and hyper responsive to tough, neck soft, kerning's
negative.

• Normal Power in left upper and lower limbs 5/5 ,

Diagnosis In view of

1.Chronic kidney disease(ESRD) with • reduced urine output,

Uraemia /Hyperkalaemia • facial puffiness,
• body swelling, nausea and vomiting
2. DM complicated with Chronic foot ulcer,
diabetic foot constipation,
gastro paresis Bloating
Tinea pedis nausea
Hx of poorly controlled sugars
Inter crease fungal infection
3. Poorly controlled Blood pressure Hx of HTN with poor adherence

4.Bilateral cataract Loss of vision

Investigations done
Parameter Result Comment
CBC Microcytic anemia
Wbc=9.37,HB=9.3,MCV 70.
Urea 38umol x7
Creatinine 1217umol x20
HBA1C 14%
RCT
NEGATIVE
Abdominal ultrasound scan Bilateral renal parenchymal
disease
Left renal simple cyst
Gaseous distention
urinalysis Glucose present ++
Pus cells++
Protein+
Abdominal xray normal
Management
• Switched to s/c mixtard 5mg stat
• Renal review done and planned for dialysis
• Surgical debridement of the ulcerated toe
• Mannual removal of the compacted stool
• Syrup lactulose 10ml bd
• P.o PantoD 1x2 for 1/52
• I.V calcium gluconate 10ml in 10mls nls
• Iv plasil 5mg bd x5/7
• p.o Amlodipine 10mgod x2/52
• Patient currently on dialysis and still on the ward.