55 yr old male with abdominal pain and sob
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A 55 YR OLD MALE WITH COMPLAINTS OF ABDOMINAL PAIN AND SHORTNESS OF BREATH
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 a series of inputs from an 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 in the comment box is welcome
A 55 yr old male patient who is resident of kammagudem came to the casuality with
Chief complaints :
Abdominal pain since 5 days
Breathing difficulty since 2 days
HOPI:
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 before 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:-
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.
Alcohol consumption since 30 yrs and currently consumes 650 ml of alcohol daily.
On examination patient is conscious, irritable
Vitals:-
BP- 120/70 mmHg
PR-111bPm
Spo2- 99%at RA.
GCS :
EYE OPENING :4 (opened spontaneously)
VERBAL RESPONSE: 3
MOTOR RESPONSE :3
Total :10
Pallor : present
Icterus : absent
Cyanosis : absent
Clubbing : absent
Lymphadenopathy : absent
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.
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:-
CNS- patient is in altered sensorium, irritable and irrelevant talk
INVESTIGATIONS:-
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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