Tuesday 11 January 2022

55 year old male patient presenting with abdominal pain and chest pain

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.


Chief complaints : 

Abdominal pain since 5 days 
Breathing difficulty since  2 days 

History of present illness: 

Patient was apparently asymptomatic 5 days back then he developed abdominal pain after taking alcohol continuously for 3 days . It is sudden in onset and gradually progressive and dragging type which is aggravated on alcohol intake and relieved on medication. Previously visited other hospitals , after onset of abdominal pain but it didn't relieve inspite of medication .
There is h/o altered sensorium since 3 days . He is unable to identify his wife and pulling away the cannulas.
There is history of nausea where he vomited by inducing with his hand . 
There is history of weight loss also since 1 year. 
History of sob which is grade 4 
History of fever yesterday.

Past history: 

A known case of diabetes since 2 years on medication .
History of TB diagnosed 2 months back on regular medication.
Not a known case hypertension,asthma,epilepsy,CVD.

Personal history: 

Bowel and bladder - regular and there is increased frequency of urine seen when sugar levels are increased .
Not sleeping adequately since 2 days 
Alcohol consumption since 30 yrs occasionally for festivals but he drinks  continuously for 3 days of 1 full bottle quantity.
History of tobacco smoking since 25 yrs.

Family history: 
Not significant


General examination:

Patient is conscious ,not co operative ,not oriented to time place person 
Not well built and nourished .
Afebrile

GCS : 
          EYE OPENING :4 (opened spontaneously)
          VERBAL RESPONSE: 3
           MOTOR RESPONSE :3 
                        Total :10
        Pallor : present
        Icterus : absent
        Cyanosis : absent
        Clubbing : absent 
        Lymphadenopathy : absent 

Vitals:-


Pulse - 90bpm 
RR - 22 cpm
Bp- 140 / 70 mm hg 
Temperature- 97.4°c 

Spo2- 99%at RA.

GRBS

5:30-600

7:30- 390

8:30-380

9:30- 383

10:30- 382

11:30- 260

12:30- 210

1:30- 220

2:30- 206

3:30- 207

4:30- 147

5:30- 77

6:30- 121

7:30- 131









Systemic examination:-


Examination of oral  cavity- 
No dental caries, no gum hypertrophy , oral hygiene is maintained , no postnasal drip 

Abdominal examination- 

INSPECTION:
Shape – scaphoid, flat,not distended
Flanks – free 
Umbilicus – Position- central, Shape-inverted
Skin –  No scars, no sinuses,no striae, no nodules,no  scratch marks,
Dilated veins – not present 
All quadrants  are equally Movable with respiration  ,no visible gastric peristalsis.
No abdominal distension .

PALPATION:
No local raise of temperature.
Superficial Palpation – Tenderness not elicited.

Deep Palpation-

Liver-
Not palpable

Spleen-
Not palpable

Kidney-
Bimanually Not palpable

PERCUSSION:
Fluid Thrill/Shifting dullness/Puddle’s sign - not elicited
Liver span - 6cm 

AUSCULTATION:
Bowel sounds are heard.

EXAMINATION OF OTHER SYSTEMS

CARDIOVASCULAR SYSTEM:
S1, S2 are heard.

EXAMINATION OF RESPIRATORY SYSTEM:
Normal vesicular breath sounds heard.

EXAMINATION OF NERVOUS SYSTEM:
Altered sensorium, irrelevant talking and unable to recognise his wife and He is pulling away the cannula.




On 9 th jan :




INVESTIGATIONS:-






Usg report-


On 11 Jan : 

Patient reviewed 
Pain decreased yesterday denies for alcohol cravings.
On examination- patient drowsy
Bp - 110/70 mmHg 
PR-102 / min
SpO2 - 98% on room air 
 
Lab investigations- 

ABG analysis: 
pH -7.44
PCo2 - 25.3 
HCO3 - 17.1 
 
Serum urea - 47 
Serum creatinine- 0.8 

Na+ - 133 
K+ - 3.2 
Cl-  - 94


Treatment:-

1. IVF- NS- 1L for 3hrs.

2. Inj HAI 6IU IV/STAT.

3. GRBS monitoring hrly.

4.IVF-5% Dextrose if GRBS<250mg/dl.

5.Inj THIAMINE 100mg in 100 ml NS/IV/BD.

6.Inj OPTINEURON 1 amp in 100ml NS/IV/OD.

PROVISIONAL DIAGNOSIS:-

Diabetic ketoacidosis with known case of diabetes milletus.


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