A 49 year old male with chest pain



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15 Feb 2022


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 Elog book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment .


Patient and his/her attenders have been informed and their consent has been taken. 


A 49 YEAR OLD MALE PATIENT WHO IS TODDY TREE CLIMBER BY OCCUPATION CAME ON SATURDAY TO OP WITH 


CHEIF COMPLAINTS OF - 

Severe chest pain since 5-6 days 

Fever and Cough since 5-6 days and 

Shortness of breath since one day 


HISTORY OF PRESENTING ILLNESS- 

Patient was apparently asymptomatic 1 week back then he developed fever which was high grade along with chills and rigor which relieved on medication. 

He also has yellowish discolouration of sclera . 

He developed  dry cough after he got fever . Chest pain aggravates on coughing since 2 days .

History of  (1 episode) vomiting when he had fever . Which was watery and had food particles in it . Non bilious 

Patient presently complains of chest pain which is aggravating on coughing and while talking along with shortness of breath since 2 days . 

Patient had similar complaints of fever with chills and rigor 4 years back when he was diagnosed to have DM along with fatty liver and jaundice. 

He has history of seizures since last 5 years . 

5-6 episodes in last 5 years . 

Last episode was 1 year back . 

FEVER CHART


Hi 



PAST HISTORY - 

Diabetes Mellitus - since past 3 years 

No history of BP , TB , Asthma, thyroid abnormalities . 


FAMILY HISTORY- 

No significant family history. 


PERSONAL HISTORY- 

Appetite- decreased 

Diet - mixed 

Sleep- inadequate 

Bowel and bladder- regular (now) 

Addictions- Chronic Alcoholic 

                    Chews Tobacco 

Chronic alcoholic- as he takes 1/2 bottle of whiskey daily since last 20 years . 


GENERAL EXAMINATION- 

Pallor - present 

Icterus- present 

Cyanosis - absent 

Lymphadenopathy- lym

Edema - absent 





SYSTEMIC EXAMINATION- 

CVS-S1 and S2 heard 

CNS-no abnormalities detected

Respiratory-bilateral air entry is present 

Per abdomen- soft , non tender 


INVESTIGATIONS- 











ECG


HEMOGRAM 

Hb- 11.6gm%

TL-17,700 cells/cubicmm

Neutrophils-87%

Leukocytes-10%

PCV-31.8

MCHC-36.5

RBC-3.7millions/cubic mm

PLT-1.6 lakh

LIVER FUNCTION TEST 

Tb-3.13

Db- 1.47

SGOT-27

SGPT-15

Alk Phosphatase - 225

TP-5.3

Alb-2.61

A/G-0.97

COMPLETE URINE EXAMINATION 

Sugars- present 

Albumin- trace 

Pus cells - 2-3

E. Cells - 3-4

Rbc- nil

KETONE BODIES- present •

BLOOD SUGAR-

RBS- 418

FBS- 269

PLBS-

HbA1C- 8.2


SERUM AMYLASE- 26IU/L

SERUM LIPASE- 17IU/L


ULTRASOUND 



CHEST X-RAY



 PROVISIONAL DIAGNOSIS


Diabetic ketosis   secondary to ? sepsis 
? Irregular medication 
With ? Left Lower lobe consolidation 
With cholelithiasis 
With DM since 4 years 



TREATMENT-



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