A 55 yr old male with complaints of abdominal pain and shortness of breath

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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 

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 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: 

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

Examination of elderly male patient .

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 

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 : (On 8 th jan ) inj HAI 6IU IV/STAT followed by insulin infusion.

5:30-600 mg/dl

7:30- 390 mg/dl

8:30-380 mg/ dl

9:30- 383 mg/ dl 

10:30- 382 mg/dl 

11:30- 260 mg/ dl

12:30- 210 mg/dl

1:30- 220mg/dl

2:30- 206 mg/ dl

3:30- 207 mg/dl

4:30- 147 mg/dl

5:30- 77 mg/dl

6:30- 121 mg/dl

7:30- 131 mg/dl

On 9 th jan :

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 followed by insulin infusion.

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.