55yrs old with abdominal pain

A 55 yr old male patient came to the hospital with 

Chief complaints : 

Abdominal pain since 5 days 

Shortness of breath - 2days

Altered sensorium -1day

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 is 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 and water as content.

On Jan 8,

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

He also complained of shortness of breath  from two days which progress from grade 2 to grade 4

History of weight loss also since 1 year. 

Past history: 

A known case of diabetes since 2 years on medication .

History of TB diagnosed 3 months back 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 6th jan(650ml)

History of tobacco smoking since 25 yrs.

(Smokes around 3 to 4 beedis per day)

Family history: 

Not significant

General examination:

At the time of presentation patient is conscious ,not co-operative ,not oriented to time place person.
Poorly built and poorly nourished

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: 

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 movable 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:

S1, S2 are heard.No added murmurs

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

EXAMINATION OF RESPIRATORY SYSTEM:

Bilateral air entry present

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.

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 8th jan:

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

Ultra sound abdomen

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.

INVESTIGATIONS:-

On 10th Jan : 

Pulse - 120bpm 

RR - 22 cpm

Bp- 120 / 80 mm hg

Temperature- afebrile

 Patient is still drowsy

On 11 Jan : 

Patient reviewed 

Pain decreased since yesterday 

Attender denies any irritable behavior and disorientation. 

Pt 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.

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 13th jan:

2 fever spikes since yesterday night 

Sensorium improved.

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 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:-

DKA (RESOLVED)

with k/c/o DM 

With k/c/o PULMONARY TB(since 3 months)

With ALTERED SENSORIUM SECONDARY TO DKA (resolved)