A 45 year old male with DKA

 This is 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 patients 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 comment box is welcome.

E.Laharika 

Roll no: 29

• I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

CASE PRESENTATION :

A 45 year old male came with chief complaints of:   chest pain since 2 days

HOPI:

Patient was apparently asymptomatic 7 years back , then he developed pain abdomen and was diagnosed with acute pancreatitis. He wasalso diagnosed with Diabetes mellitus. 

Patient was chronic alcoholic since 20 years -360 ml/ day.  He is being an occasional alcoholic since 7 years. He had history of binge alcohol 2 days back 90 ml night and morning , then developed chest pain.

He also has SOB grade 3

No h/o palpitations and syncopal attacks 

No h/o orthopnea, paroxysmal nocturnal dyspnoea 

PAST HISTORY:

Patient is a k/c/o DM since 7 years

No h/o HTN,Epilepsy, Asthma

GENERAL EXAMINATION:

Pt is conscious, coherent and cooperative. 

Pallor, Icterus, Cyanosis, clubbing, lymphadenopathy- absent

VITALS:

Temp : afebrile

Bp: 120/80 mm hg

PR :87

RR: 16

Spo2: 100

GRBS : 468

SYSTEMIC EXAMINATION:

CVS : S1 S2 heard

RS : BAE +

         SOB grade 3

P/A : Non tender

CNS: speech is normal 

         Reflexes are normal 

          Sensory and motor systems intact

           

           

           

INVESTIGATIONS:

Ultrasound 

ECG ON 21/2/22

ECG ON 22/2/22:

                 

Chest x ray:

PROVISIONAL DIAGNOSIS:  

    Diabetic ketoacidosis

TREATMENT:

1.Inj HAI  6 U   iv /stat 

2.inj HAI 1ml in 39 ml ns according to infusion algorithm 

3.inj pantop 40 mg iv /bd 

4.inj zofer 4 mg iv /sos