A 63-year-old male with a history of 3 years diabetes mellitus is complaining of muscle cramps at the back of his left thigh while walking for last 3 days. He has a hstory for diabetes mellitus type 2 for past 3 years. He is not taking any medicines for his diabetes. On general examination, he has no anemia, jaundice, cyanosis. He has no hepatomegaly or splenomegaly. His BP is 135/85 mm Hg. Cardiac and respiratory examination is normal. On skin examination, he has reddish non-pruiritic, painless skin lesions over the anterior-lateral aspect of lower right thigh and right leg for the same duration. He never had these lesions before. (his skin lesions are attached below). His random blood glucose level is 9.1 mg/dl.
This is a 55 year old man in ICU with severe hypercapnia refractory to positive pressure ventilation with PCO2 ranging from 100-120 mm of Hg after 24 hours of ventilation. He appeared to have a history of Bronchial asthma since childhood. Perhaps for the last 45 years. His last three years appear to have been spent in perennial shortness of breath and wheeze. He has a barrel shaped chest and his CXR pa shows pushed down diaphragms. He was referred from a nursing home on a ventilator ambulance and his ABG during admission was showing a PCO2 of 90. After 24 hours of ACMV with a RR of 20 and tidal volumes of 400 ml his PCO2 increased to 120s. This case of AECOPD with resp. Acidosis on mechanical ventilator was found to have total WBC count increasing overtime (15300 (ICU 2nd Day)/ 18500/ 27500/ 35600 (13th day). So, we started empirically with Clavum & Augmentin and later on planned for meropenam & Colistin antibiotic based on further deterioration in Total WBC Count....





Glucagonoma, necrolytic migratory erythema.
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