55 yr old male with abdominal pain and chest pain , shortness of breath

 55 yr old male with abdominal pain, chest pain, shortness of breadth. 

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

N. Raveela
Roll. No :95


55yr old male came to the opd with cheif complaints of abdominal pain 5 days and chest pain 2 days. 

HOPI: 
Patient was apparently asymptomatic 5days back ,then he consumed alcohol for 3 days without taking proper food and started developing abdominal pain ,which is sudden in onset , dragging type , gradually progressive ,aggrevated by alcohol intake and relieved on medication 
• Sob since 1 day which is grade 4 (severe)
• altered sensorium (self talking )
• history of weight loss since 2 years

PAST HISTORY

•Patient is k/c/o Diabetes since 2 years and he is on medication 
•Patient is k/c/o Tuberculosis (diagnosed 2 months back )and he is on medication 
•No history of Hypertension, astham, epilepsy

PERSONAL HISTORY

• Bowel and bladder movements - Regular
• Not sleeping adequately since 2 days 
• Alcohol consumption since 30 years 
• Tobacco smoking since 25 years 

FAMILY HISTORY 

•Not significant 

GENERAL EXAMINATION

•Patient is conscious ,not co operative ,not oriented to time place person 




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

SYSTEMIC EXAMINATION INSPECTION:

ABDOMINAL EXAMINATION:

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.

CVS :S 1 ,S2 heard 

 CNS : Altered sensorium , irrelevant talk 

  RESPIRATORY SYSTEM : Vesicular breath 
      Sounds heard

GRBS : (On 8 th jan )
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

On 9 th jan :












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.

7.lorazepam iv
PROVISIONAL DIAGNOSIS:-

Diabetic ketoacidosis with known case of diabetes milletus.

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FINAL MBBS PRATICAL EXAMINATION: SHORTCASE This is 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 patients 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 comment box is welcome. N. Raveela Hall ticket no: 1701006123 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 a diagnosis and treatment plan.   CONSENT AND DE-IDENTIFICATION :  The patient and the attenders have been adequately informed about this documenta...
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