25M with chest pain and sob

 

25 YR OLD MALE WITH CHEST PAIN, VOMITINGS AND SOB 

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


A 25 YEAR OLD FEMALE WITH FEVER AND HEADACHE 
Date of admission : 7-2-23

25/M painter by occupation who was apparently asymptomatic 9 years back,
Patient c/o blurring of vision for which he went to local hospital used medication but his blurring of vision(Rt>>Lt) wasn't subsided 
In 2014 patient c/o severe weight loss approximately 10-12 kgs over a duration of 2 months. And having increased apetite, increased frequency of urination with these complaints he went to Local hospital and diagnosed with type 1 diabetes mellitus and since then he was started on Mixtard insulin 28U -x - 24U and since then he is on regular follow up.. His fbs used to be around 200-250 and ppbs around 250-300
Last HbA1c was 11.2 on feb 3rd 
Now since 1 week patient came with c/o fever high grade associated with chills and rigors, Nausea, Vomitings , constipation
And c/o neck pain
No c/o chest pain palpitations , syncopal attacks 
No meningeal signs 

At presentation his grbs is 234  mg/dl with urine for ketones ++ 

Outside 24hr urine proteins 3920mg/day 

On presentation his vitals are 
Afebrile 
BP - 110/80 mmhg
PR - 86bpm
Spo2 - 100 at RA
CVS - S1S2+
RS - normal vesicular breath sounds heard 

On HAI infusion according to Algorithm 1

 
Not a k/c/o HTN / Asthma / CAV / CAD

Personal history :
Sleep: adequate 
Appetite: normal 
Diet: mixed
Bowel and bladder movements: normal 
Addictions: none 

Family history : 
No similar complaints in family 

General examination :
Patient Is conscious, coherent, cooperative moderately built and well nourished 
pallor - Absent 
icterus - Absent
clubbing - Absent
cyanosis - Absent
lymphadenopathy  - Absent
Edema  - Absent

Vitals:
TEMP-96.5 F
PR-82/MIN
RR-14/MIN
BP-110/70MMHG
SPO2-99% AT ROOM AIR
GRBS-197MG%. 

Systemic examination :
CVS - S1S2 present, no murmur
RS - Bilateral air entry present, trachea central in position 
CNS - Higher mental functions intact 
P/A - Soft, non tender

Clinical images with investigations:

    ECG DONE ON 8-2-23 
   ECG DONE ON PRESENTATION 8-2-23
    REPEAT ECG 8-2-23
    USG ABDOMEN DONE ON 8-2-23
    2D ECHO DONE ON 8-2-23
    BLOOD AND URINE INVESTIGATIONS 


Diagnosis :
DIABETIC KETOACIDOSIS(RESOLVED) WITH OLD INFERIOR WALL MI WITH K/C/O TYPE I DM SINCE 9YRS WITH DIABETIC NEPHROPATHY 
 

Treatment :
* IV FLUIDS NS@75ML/HR
 5% DEXTROSE IF GRBS <= 250MG/DL
* HUMAN ACTRAPID INSULIN INFUSION ( 1ML +39 ML NS) @ 3ML/HR BASED ON GRBS 
* TAB ECOSPRIN GOLD 75/75/10MG PO HS  
* GRBS MONITORING HOURLY
* STRICT I/O CHARTING.
* VITALS MONITORING 2ND HRLY.


SOAP NOTES : 


Date : 08/02/23
ICU 
Unit 2 
DR..AASHITHA SR
DR.PRADEEP PGY3
DR. VINAY PGY3
DR.NARASIMHA PGY2
DR.AJAY PGY1
DR.PARCHETHAN PGY1
DR.JATIN INTERN
DR.SANTHOSH INTERN

S
 STOOLS NOT PASSED 
NO FEVER SPIKE 

O
PATIENT IS CONSCIOUS COHERENT COOPERATIVE .
VITALS:
TEMP-96. 5F
PR-82/MIN
RR-14/MIN
BP-110/70MMHG
SPO2-99% AT ROOM AIR
GRBS-197MG%.

SYSTEMIC EXAMINATION:
P/A- SOFT  NON TENDER 
CVS-S1 S2 PRESENT,NO MURMURS
RS-B/L AIR ENTRY PRESENT,NVBS HEARD
CNS-NAD

A:
 DIABETIC KETOACIDOSIS WITH OLD INFERIOR WALL MI WITH K/C/O TYPE I DM SINCE 9YRS WITH DIABETIC NEPHROPATHY 

P:
* IV FLUIDS NS@75ML/HR
 5% DEXTROSE IF GRBS <= 250MG/DL
* HUMAN ACTRAPID INSULIN INFUSION ( 1ML +39 ML NS) @ 3ML/HR BASED ON GRBS 
* TAB ECOSPRIN GOLD 75/75/10MG PO HS  
* GRBS MONITORING HOURLY
* STRICT I/O CHARTING.
* VITALS MONITORING 2ND HRLY.


Date : 09/02/23

ICU 
Unit 2 
DR..AASHITHA SR
DR.PRADEEP PGY3
DR. VINAY PGY3
DR.NARASIMHA PGY2
DR.AJAY PGY1
DR.PARCHETHAN PGY1
DR.JATIN INTERN
DR.SANTHOSH INTERN

S
 STOOLS NOT PASSED 
NO FEVER SPIKE 

O
PATIENT IS CONSCIOUS COHERENT COOPERATIVE .
VITALS:
TEMP- AFEBRILE 
PR-82/MIN
RR-18/MIN
BP-110/70MMHG
SPO2-98% AT ROOM AIR
GRBS-216MG%.

SYSTEMIC EXAMINATION:
P/A- SOFT NON TENDER 
CVS-S1 S2 PRESENT,NO MURMURS
RS-B/L AIR ENTRY PRESENT,NVBS HEARD
CNS-NAD

A:
 DIABETIC KETOACIDOSIS(RESOLVED) WITH OLD INFERIOR WALL MI WITH K/C/O TYPE I DM SINCE 9YRS WITH DIABETIC NEPHROPATHY 

P:
* IVF NS @ 75ML/HR
* INJ HAI 14U---14U---14U
  INJ NPH 20U---×---20U
* TAB ECOSPRIN GOLD 75/75/10MG PO HS  
* TAB TELMA 40MG PO OD 
* GRBS CHARTING 
* STRICT I/O CHARTING.
* VITALS MONITORING

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