55 year male with abdominal pain

  12/01/22

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A 55 year old male presented with altered sensorium and pain abdomen.

K.Lasya Mithra, 9th semester

Roll No: 50

I have 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.

CASE: 

A 55 year old Male came to hospital with

CHIEF COMPLAINT:

Abdominal pain since 5 days 

Shortness of breath- 2 days

Altered sensorium- 1 day

History of present illness: 

Patient was apparently asymptomatic 2 weeks back then he developed abdominal pain after taking alcohol continuously for 3 days . It is sudden in onset and gradually progressive and dragging type , non radiating which  aggravated on alcohol intake and relieved on medication.He had an episode of vomiting after intake of alcohol for 3 days which is non bilious , non projectile water as content. 

On jan 8th,

 He developed severe abdominal pain associated with altered sensorium and presented to our hospital. 

He also complained of  shortness of breath from 2 days which progressed from grade 2 to grade 4.

history of weight loss also from 1 year. 

Past history: 

A known case of diabetes since 2 years on regular medication .

History of TB diagnosed 3 months back and on regular medication.

Not a known case of  hypertension,asthma,epilepsy,CVD.

Personal history: 

Appetite - normal

Diet - mixed

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 ,he drinks  continuously for 3 days of 1 full bottle and doesn't consume for 10 days.His last binge of alcohol was on jan 6th - 650 ml.

History of tobacco smoking since 25 yrs.( smokes - 3 to 4 beedis per day.)

Family history: 

Not significant

General examination:

On presentation , patient is conscious ,not co operative ,not oriented to time place person 

Poorlybuilt and poorly nourished .

• GCS : score 10

          Eye opening - 4

          Verbal response - 3

          Motor response - 3

       

•         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: 

Abdominal examination- 

INSPECTION:

Shape – scaphoid, flat,not distended

Umbilicus – central and inverted

Skin –  No scars, no sinuses,no striae, no nodules, no dilated veins.

All quadrants  are equally moving with respiration  ,

no visible gastric peristalsis.

PALPATION:

No local raise of temperature.

Tenderness not elicited.

Liver-

Not palpable

Spleen-

Not palpable

Kidney-

Bimanually Not palpable

PERCUSSION:

Fluid Thrill/Shifting dullness - not elicited

Liver span - 6cm 

AUSCULTATION:

Bowel sounds are heard.

EXAMINATION OF OTHER SYSTEMS

CARDIOVASCULAR SYSTEM:

Apex beat heard at 5th intercoastal space medial to mid clavicular line.

S1, S2 are heard, no added murmurs.

RESPIRATORY SYSTEM:

Trachea-  central 

Bilateral air entry present 

Normal vesicular breath sounds heard.

NERVOUS SYSTEM:

Altered sensorium, irrelevant talking and unable to recognise his wife and he is pulling away the cannula.

Higher mental functions normal.

Cranial nerve examination- normal

Meningeal signs were absent.

Cerebellar functions normal.

Sensory examination: sence of fine touch, vibration, coarse touch are normal.

Motor examination:

Power: upper limbs: 5 bilaterally

              Lower limbs: 5 bilaterally.

Tone: Normal

Reflexes:          R.             L

 

Biceps:.            N.             N

Triceps:.           N.             N

Knee.                N.             N

Ankle:              N.             N 

INVESTIGATIONS:

On jan 8th,

GRBS : 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

ULTRASOUND (abdomen) REPORT:

On 9 th jan :

 

Vitals:

Pulse - 110bpm 

RR - 22 cpm

Bp- 120 / 90 mm hg 

Temperature- afebrile

GRBS - 193 mg/dl

Patient is drowsy and was oriented to time,  place and person on repeated questioning.

On 10th  Jan : 

Pulse - 120bpm 

RR - 22 cpm

Bp- 120 / 80 mm hg

Temperature- afebrile

 Patient is still drowsy

On jan 11th:

Patient reviewed

Patient is drowsy

Attender denies any irritable behavior and disorientation. 

Pain decreased since yesterday

Vitals:

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.

On 12 th jan:

Patient is conscious,  coherent and well oriented to time, place and person. 

 

Vitals: 

Grbs:160mg/dl

Bp:120/80mmhg

PR: 94bpm

Spo2: 99%@room air

RR : 20 cpm

Treatment:

1.IVF- NS,RL- @150ml/hr

2. Inj HAI AND NPH ACCORDING TO GRBS

3.Inj THIAMINE 200mg in 100 ml NS/IV/BD.

4.Inj OPTINEURON 1 amp in 100ml NS/IV/ OVER 30 MIN /OD.

5. INJ PAN 40MG IV/OD

6. INJ ZOFER 4 MG /IV/SOS

7.INJ LORAZEPAM 1 amp IM /SOS.

On jan 13th,

Patient sensorium improved and had mild fever yesterday night.

Vitals:

Grbs:160mg/dl

Bp:120/80mmhg

PR: 94bpm

Spo2: 99%@room air

RR:  20

Treatment:

1.IVF- NS,RL- @150ml/hr

2. Inj HAI SC ACCORDING TO GRBS

3. TAB. ZINCOVIT PO/OD

4. TAB. BENFOMATE PLUS PO/OD

5. TAB. PAN 40 mg PO/OD

6. TAB. ZOFER 4 MG /PO/SOS

7. TAB. LORAZEPAM 2 mg PO/SOS

8. TAB. PCM 650 mg PO/TID

PROVISIONAL DIAGNOSIS:-

Diabetic ketoacidosis with known case of PULMONARY TB(since 3 months)

with altered sensorium secondary to DKA (resolved)