25M with chest pain and sob
25 YR OLD MALE WITH CHEST PAIN, VOMITINGS AND SOB
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2D ECHO DONE ON 8-2-23
BLOOD AND URINE INVESTIGATIONS
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
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
