Case of 48Y old male with chest pain and shortness of breath. 

This is an online E-Log book to discuss our patient's de-identified 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 these patient's clinical problems with collective current best evidence-based inputs. This E-log also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.

CASE:

A 48 years old male came to casualty with

CHIEF COMPLAINTS:

Chest pain since 2 hours,
Shortness of breath since one day.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 4days ago when he developed high grade fever a/w chills and rigor intermittent type, relieved on medication; cold and dry cough  since two days aggravated during night.
He had one episode of vomiting four days ago- non projectile, non bilious, had food particles.
No c/o abdominal pain.
No c/o Orthopnea, PND.

PAST HISTORY:


Patient had similar episodes since five years, and multiple hospital admissions for every 6 months due to fever and jaundice.

Patient was diagnosed with DM five years ago and was on OHA- irregular medications.

Patient has h/o seizures four years ago, first episode was when he was traveling in train from Gujarat to Hyderabad with high fever;  tongue bite+ 2years ago, last episode was 1 year ago, was unconscious for 5mins, postictal confusion+.

H/o multiple RTA s with minor injuries over left hand, left knee, right eye, right ankle

H/o covid + 1 year back 
Received 1 dose of vaccine - covishield 

Not a k/c/o HTN, ASTHMA,TB.

FAMILY HISTORY:

Patient's both the parents are diabetic, he has 3 siblings 1 brother and 2 sisters out of which one sister and one brother are diabetic.

PERSONAL HISTORY:

Patient lives in Gujarat for 6months for work and 6 months later visits his family.
 
DAILY ROUTINE before illness:
  • 4am- wakes up and goes to work (Toddy tree climber)
  • 6am- comes back home
  • 8am-fresh up
  • 9am- breakfast
  • 2pm-5pm lunch and sleep
  • 5pm-7pm work
  • 8pm- dinner
  • 10pm- sleep
    After illness: There is no significant change in his daily routine except for he reduced his working hours.

  1. Diet: mixed
  2. Appetite: adequate
  3. Sleep: adequate
  4. Bowel and bladder: regular
  5. Addictions: alcohol consumption since 20years, heavy drinking since 10 years 360-480ml/day.
  6. No h/o Surgeries, allergies,other addictions.
  • He visited REHABILITATION CENTRE at Hyderabad 2 years ago for 6months and brought back for his daughter's marriage and  sent back for 2 months and brought back.

GENERAL EXAMINATION:


The patient was examined in a well-lit room after informed consent was taken.
He is conscious, coherent, cooperative, well oriented to time, place and person. He was well nourished and moderately built.

No Pallor, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.
Icterus+


VITALS:
  1. PR: 100bpm
  2. RR: 22cpm
  3. BP: 120/80 mmHg
  4. Temperature: 99°F
  5. GRBS: 396mgdL
  6. SpO2: 90% on room air.







SYSTEMIC EXAMINATION:

  1. CVS: S1 and S2 heard, no murmurs heard.
  2. CNS: NAD
  3. Per Abdomen:Soft, non tender, no distension, umbilicus is central and inverted,no scars, no sinuses.
  4. RS: Bilateral air entry present ,  reduced breath sounds in LEFT IAA , IMA, ISA , wheeze + 

INVESTIGATIONS:

ABG


HbA1C


FBS


LIPID PROFILE


SERUM AMYLASE


LIPASE


RFT


LIVER FUNCTION TEST


COMPLETE URINE EXAMINATION


HEMOGRAM


ECG


CHEST X-ray


 COLOUR DOPPLER 2D ECHO


USG CHEST


USG ABDOMEN



PROVISIONAL DIAGNOSIS: 

Diabetic ketosis secondary to ? sepsis 

? Left lower lobe consolidation

With cholelithiasis 

With DM since 4 years 


TREATMENT: 

1. Inj PAN 80 mg/iv/stat

2. Inj. Zofer 4 mg/iv/stat

3. Inj. HAI 1 ml in 39 ml NS iv/according to grbs

4. Inj. PAN 40 mg/iv/bd

5. Inj. Zofer 4mg /iv/tid

6. Inj. Augmentin 1.2gm /iv/tid

7. Tab. Azithro 500 mg po/od

8. Inj. Thiamine in 100 ml NS/iv/tid

9. Inj. Optineuron 1 amp in 100 ml NS/iv/od

10. IVF NS, RL @ 100 ml/hr

11 Hourly GRBS charting.







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