Medicine E-log

Case history: 

A 54 year old male patient came with Pain in the left side of the chest radiating to the back side since 2 days, difficulty in breathing since two days.

Patient was apparently asymptomatic 2 days back then he developed pain in the left side of chest all over, of stabbing type, which increased on inspiration, radiating to the left upper back.

Pain ass with difficulty in breathing in breathing (a sense of difficulty/strain during inspiration).

No history of shortness of breath.

No history of palpitations orthopnoea, PND, headache, burning micturition, vomiting loose stools, cough fever

Patient has complete loss of vision in both eyes since 10years patient was apparently asymptomatic 12 years back then he developed severe dragging type of pain in both the eyes for which he went to the doctor & was diagnosed to have glaucoma & was given medication which he used for 2 years with no improvement.

He was also operated 10 years back due to loss of vision, but there was no improvement in vision despite surgical intervention, but the pain had improved.

There is no history of HTN DM epilepsy asthma CVA CAD.

GRBS values on presentation turned out to be 740mg/dL

No history of headache, tingling sensation, numbness.

No history of decreased urine output.

History of burning sensation of both feet since 1 year.

On Examination the patient was conscious coherent and cooperative.

Febrile -100F

PR 104BPM

BP 160/100mmHg

RS BAE+ decreased breath sounds in left ISA coarse crepitations in lt IAA

CVS S1 S2 heard no murmurs

P/A soft non tender

Investigations:

On day 1:

ECG at presentation: 

ABG at presentation showed slightly decreased levels of pCO2

Random blood sugars elevated- 740mg/dL

Complete urine examination showed elevated sugar levels

Urine was also tested was ketone bodies which turned out to be negative.

Hemogram shows increased TLC- 19,800 & increased neutophil levels 

Renal functions were mostly normal, phosphorus levels were slightly elevated in the patient

Serum osmolality was elevated- 324mOSM/kg

Chest X-ray on the first day shows slight effusion on the left lobe

Treatment:

9/6-

9pm- 538

10pm- 537

11- 472

10/6

12am- 437

1- 320 

2- 266

3- 241

3:30- 229

4- 245

4:30- 274

5- 257

5:30- 317

6- 339 (1 unit of insulin in 39 parts of NS)

6:30- 435

7:30- 485

8:30- 446

10- 421

10:30- 413

11:30- 368

12:00- 431

12:30- 302

1:00- 346

1:30- 343

5pm- 316; 99.8F

7pm- 290

8pm- 1 unit subcutaneous insulin 

10pm- 278

11/6 (GRBS Value in mg/dL)

12am- 238

2am- 179

4am- 164

6am- 157

8am- 271 (post breakfast)

9am- T.Glimiperide

10am- 264

12pm- 193; 101.2F

2pm- 203; 102.2F

4pm- 314

6pm- 319

8pm- 1/2 tab. Glimiperide 

10pm- 361

12/6

1am- 268

4am- 254

6am- 238

8am- 238

9am- T.GLIMIPERIDE 

10am-264

Fever chart:

Chest X-ray on day 4:

Culture sensitivity report showed klebsiella:

Chest radiograph and HRCT reports:

Pleural fluid- negative for malignant cytology; 

Sediment smear was studied it showed scanty cellularity of Lymphocytes and few neutrophils only against eosinophilic proteinaceous background

Pleural sugar- 124mg/dL (elevated); pleural protein- 5g/dL, pleural LDH- 2240IU/L (elevated), pleural fluid ADA: 24U/L

Chest X-ray day 6: 

USG- Chest shows thick septations and collapsed lung with minimal fluid

The ICD intervention would not be possible as there is less space

Consider breakage of loculations and septations through surgical intervention.

Bacterial culture negative for any aerobic bacteria.

Treatment: 

1. Propped up position 

2. Inj. piptaz 4.5gm/IV/TID day 7

3. Inj. Pan 40mg/IV/OD

4. T. Glimiperide  BD (2.5mg - 1.5mg)

5. T. Ultracet 1/2 tab QID

6. BP PR RR hourly

7. GRBS 4th hourly

8. T vitC 1000mg/OD

9. T Telma 40mg/od

10. Inj neomol 1gm/iv infusion if temp >101F

11. Strict I/O charting

Diagnosis:
Left sided moderate loculated pleural effusion with left lower lobe pneumonic consolidation (exudative viral? Bacterial?)
Denovo HTN DM2

Cholelithiasis