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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
PATIENTS INTAKE AND OUT PUT CHARTS
9TH 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.
