55 Years Old C/o Abdominal Pain

GEN MED CASE: 55 yrs old male patient  came with chief complaints of abdominal pain since 5 days and chest pain since 2 days

 Student- y.rahul

Batch- 2017

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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CHEIF COMPLAINTS:

Patient came with cheif complaints of abdominal pain since 5 days and chest pain since 2 days.

HISTORY OF PRESENT ILLNESS: in

Patient was apparently asymptomatic 1 week back and then he consumed alcohol(650ml)  for 2 days continuously and he developed abdominal pain which is dragging type,non radiating.

C/o chest pain dragging type,non radiating to left arm.

C/o vomiting 3 days back .

Past history:-

There is similar episodes in the past with abdominal pain, vomiting since 2 years at the time of alcohol consumption only. And it is treated with IV fluids at local hospital.

Patient is k/c/o DM since 2 yrs and on oral hypoglycemic drugs.

Personal history:-

Diet - mixed

Appetite- normal

Sleep - adequate

Bowel and bladder movements - regular.

Alcohol consumption since 30 yrs and currently consumes 650 ml of alcohol daily.

Smoking (beedi) since 10 years 3 per day.

On examination, patient is conscious, irritable and with altered sensorium.

Vitals:-

BP- 120/70 mmHg

PR-111bPm

Spo2- 99%at RA.

GRBS- 600

CLINICAL PICTURE

Systemic examination:-

CNS- patient is in altered sensorium, irritable and irrelevant talk

INVESTIGATIONS:-

On day 1 insulin 6 units of insulin is given.

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

Day 2

S: pt is in altered state of sensorium and irritable

Irrelevant talk

No fever spikes

O: pt is on insulin infusion @4ml/hr

Grbs:100mg/dl

Bp:120/80mmhg

PR: 94bpm

Spo2: 99%@room air

RR : 20

Grbs values:

8:30 am-100

A: DKA with k/c/o DM 

P:

IVF- NS- 1L for 3hrs.

2. Inj insulin is given

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.

Treatment:-

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

2. Inj insulin is given.

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.