A couple who was into agricultural works had 4 children, 2 sons and 2 daughters. The 2 nd son had no visible umbilicus at birth. He also had increased breast tissue mass bilaterally during the childhood.
                           He got married at the age of 15 years but he and his wife didn't conceive children for the next 25 years. He married again and with the second wife he had 4 children, all 4 sons.
                            He gives h/o fall from a tractor 15 years back after which he tells to have developed a defect in the abdominal wall near the umbilical region and developed a swelling which gradually progressed over the years.



                            He later had a thorn prick in the left foot 10 years back which later progressed into swelling and colour change in the left foot. He went to a local hospital where he was diagnosed to be having Diabetes mellitus. His foot had to be amputated because of gangrenous change.



                         Gives history of pain in the left lumbar region which was colicky in nature radiating to the groin region one year back for which investigations were carried out which revealed a calculus in the left kidney. ?Percutaneous nephrolithotomy was done.
                         5 months back he complained of hard dark colored stools on and off for 2 months for which he took no treatment and had subsided. No h/o painful defecation or passage of blood in stools.
                         Since the past 4 months he has h/o fever intermittently on and off. Complains of shortness of breath even on doing daily activities since the past 2 months which gradually aggravated 2 weeks back. Gives history of developing an ulcer on the right foot on the lateral side 2 weeks back which was non healing and was debrided regularly and dressings were done.
                         Complains of dribbling of urine and pain in the left lumbar region which is colicky and radiating to the umbilical and the groin regions for the past 15 days. Later he had presented to a local clinic where he was told be having aablood pressure recording of 150/100 for which he was started on anti hypertensive medication. He presented to the urology OP 5 days back with complaints of dribbling, lumbar pain and dyspnoea.
                           As no active urological intervention was needed he was referred to the medicine department for shortness of breath.

Personal history

Mixed diet.
Reduced appetite 2 weeks.
Irregular bowel habits with hard stools once in 3 days.
Dribbling of urine on and off.

Drug history

Taking Human mixtard insulin 10units in the morning and 10 units in the night since 1 year.
Aten 50 mg once a day for the past 1 week.

General examination

Moderately built and nourished man with central obesity and muscular wasting is conscious and we'll oriented to time place and person.
Gynaecomastia noted
Has a swelling in the abdomen near the umbilical region which roughly approximates to 5*4 cms.
Healing ulcer noted in the right foot on the lateral aspect. 
Left great toe and medial 2 toes are amputated.




His spo2 at room air is 98%.
Blood pressure: 130/90 mmhg in supine position in right arm
Pulse rate: 80 bpm regular in right radial artery.
Respiratory rate: 25 cpm
Cardiovascular system: s1s2 heard.
Respiratory system: All the lung areas bilaterally have equal air entry.
Per abdomen: Swelling noted near the umbilical region of about 5*4 cms approximately.
Soft in consistency.
No tenderness present.
No organomegaly.
Per rectum: Grade 1 prostatomegaly noted.

INVESTIGATIONS

Complete blood picture

Hb: 6.3 gm% 
TLC: 75000
N:90
L:05
B:0
E:02
M:03
Platelets:6.6 lakh 
Peripheral smear:

 R.B.C- Microcytic/Hypochromic mild anisocytosis
W.B.C - Increased on count with shift on the left side with neutrophilic leukocytosis
Platelets- Increased on count

Impression:
Microcytic/hypochromic with neutrophilic leukocytosis and thrombocytosis.
LEUKAMOID REACTION

Complete urine examination

Albumin- 1+
Sugar- nil
Pus cells - 4-5 
Epithelial cells- 3-4

Liver function test

Total bilirubin: 1.10
Direct bilirubin: 0.48
Sgot: 11
Sgpt: 5
Alkaline phosphatase: 225
Total proteins: 6
Albumin: 2.8
A/G ratio: 0.88

Renal function tests

Blood urea: 101
Serum creatinine: 2.9
Uric acid: 11.7
Calcium: 10.5
Phosphorus: 3.3
Sodium: 151
Potassium: 3.9
Chloride: 114

HbA1c- 

6.6%

APTT- 41sec
PT- 20sec
INR- 1.45
BT- 2 minutes
CT- 2 minutes









Complete blood picture Day3

Hb: 6.5 gm% 
TLC: 80000
N:82
L:03
B:0
E:01
M:00
Platelets: 4.17 lakh 
Band forms:06
Myelocytes:03
Metamyelocytes:05
Peripheral smear:

 R.B.C- Microcytic/Hypochromic macroovalocytes
W.B.C - Increased on count with shift on the left side with neutrophilic leukocytosis
Platelets- High normal with few giant forms


Impression:
Microcytic/hypochromic with neutrophilic leukocytosis.
LEUKAMOID REACTION


Ultrasound abdomen

3.9 cm defect in the anterior abdominal wall near the umbilical region.
Mild splenomegaly
Left hydroureteronephrosis

CT abdomen

Contracted gall bladder s/o calculi or sludge
Left hydroureteronephrosis
Left renal calculi









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