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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 :
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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