GENERAL MEDICINE Prefinals paper 2

General medicine PREFINALS paper I

                                     PAPER 1

A 55 YEAR OLD MALE WITH ABDOMINAL PAIN , SHORTNESS OF BREATH AND ALTERED SENSORIUM

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CHEIF COMPLAINTS:

Patient came to the OPD with cheif complaints of abdominal pain since 5 days , chest pain since 3 days and shortness of breath since 2 days and he was talking to himself and was not able to recognise his wife.

HOPI :

      Patient was apparently asymptomatic 1 week back ,then since January 1st he consumed alcohol for 3 days without taking any food orally.

He used to induce vomiting,

later he started developing

• Abdominal pain  ,which is sudden in onset , dragging type , gradually progressive ,aggrevated by alcohol intake and relieved on medication.(He continued to take alcohol even after taking medication.) 

•chest pain - dragging type,non radiating to left arm

• Sob since 2 days which is grade 4 (severe)

• altered sensorium (self talking & couldn't recognise his wife) 

• history of weight loss since 2 years

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 Diabetes since 2 years and he is on Oral hypoglycemic drugs

•Patient is k/c/o Tuberculosis (diagnosed 2 months back )and he is on ATT 

(which he is not taking since 10 days)

•No history of Hypertension, astham, epilepsy

PERSONAL HISTORY:

• Bowel movements - Regular

•Bladder - polyuria 

• Not sleeping adequately since 2 days 

• Alcohol consumption since 30 years 

currently patient drinks 650 ml per day 

last binge on 6th January

• Tobacco smoking since 25 years 

3 - 4 beedis per day 

FAMILY HISTORY 

•Not significant 

GENERAL EXAMINATION

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

GCS : 

          EYE OPENING :4 (opened spontaneously)

          VERBAL RESPONSE: 3

           MOTOR RESPONSE :3 

                                       Total :10

VITALS : 

BP- 120/70 mmHg

PR-111bPm

Spo2- 99%at RA.

GRBS- 600

        Pallor : present

        Icterus : absent

        Cyanosis : absent

        Clubbing : absent 

        Lymphadenopathy : absent 

SYSTEMIC EXAMINATION 

      CVS : S 1 ,S2 heard 

      ABDOMEN : Diffuse pain over abdomen

      CNS : Altered sensorium , irrelevant talk 

      RESPIRATORY SYSTEM : Vesicular breath 

      Sounds heard.

On day 1

 6 units of insulin is given

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  and 10th jan 

INVESTIGATIONS

ECG

Clinical images

PATIENTS INTAKE AND OUT PUT CHARTS

9TH JANUARY

10TH JANUARY

 Urine out put (7.30 pm) 

Day 2

SOAP NOTES 

S:(Subjective): 

pt is in altered state of sensorium and irritable

Irrelevant talk

No fever spikes

O:( objective) 

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:(Assesment)

DKA with k/c/o DM 

P: (Plan) 

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.

Day 3 :

ICU bed no1

SOAP NOTES 

S:(Subjective)

 pt is in altered state of sensorium and irritable

Irrelevant talk

1 fever spike

O:( objective) 

 pt is on insulin infusion @2ml/hr

Grbs:198mg/dl

Bp:120/80mmhg

PR: 94bpm

Spo2: 99%@room air

RR 20

A:(Assesment)

 DKA with k/c/o DM 

P: (Plan) 

IVF- NS- @100ml/hr

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.

TREATMENT

IVF- NS- @100ml/hr

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.

inj Lorazepam 2mg 1/2 amp IM 

PROVISIONAL DIAGNOSIS:-

Diabetic ketoacidosis with known case of diabetes milletus.