35 year old male with pain in left side of chest region and vomitings

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Case

35 year old Male patient who is a resident of Nalgonda and Biochemistry teacher by occupation came with a chief complaints of

 • Pain in the lower chest region on left side since 19 days 

• Vomitings since 14 days

History of presenting illness:

▪Patient was apparently asymptomatic 7 years back then he fell from bike due to fainting then he was diagnosed as diabetic at local hospital since the he was on medication( metformin- 500 mg) regularly till 2019 and was on regular checkup monthly with dietary practices

▪ He used to drink alcohol occasionally since 2008 and smoke 1-2 cigarettes per day during his working hours. He started drinking alcohol heavily since 2019 January due to personal problems and smokes half packet of cigarettes whenever he takes alcohol and was not on regular medications for diabetes then after 2 weeks he had vomiting and abdominal pain for which he was hospitalized and diagnosed acute pancreatitis and his blood sugar levels was very high for which he was given insulin  form of therapy then he was on GLYCOMET -MV1  (Metformin and Voglibose)

▪ Then he stopped drinking alcohol for 2 months during this period of 2 months he was alright

▪Then he again started drinking and was not regular on diabetic medication and then he had recurrent episodes of abdominal pain and some times vomitings following heavy drinking for which he stops taking alcohol for 2 days and then he resumed again

▪3 years ago patient had corn on plantar aspect of great toe, patient himself used to cut the thickened part with a blade, which one year ago turned into an ulcer, for which he underwent debridement 1 year ago and 4 months back. He does his own dressing by using spirit to clean and the area and then puts iodine and cotton on it, every alternate day but it was not healed and some times he had pain which was radiating upto ankle joint

▪He quit his job 2 years ago and is only staying at home since then, but occasionally teaches as a guest lecturer.

▪Since 1 year, he is experiencing burning sensation in his feet, tingling sensation from his foot to his calf.

▪He has pedal edema till in ankle in his left foot, which is of pitting type, and seen only at the end of the day , now it has subsided 

▪ He had accident 19 days back when he was drunk and then he developed pain and swelling but he neglected it because he was on alcohol totally and did not take any food for 4 days Pain which was gradually increased which was throbbing type and non radiating and increased on taking deep breath and on lying on left lateral position relieved on medication

▪ After 4 days he had single episode of vomiting at night which was blood stained so he stopped taking alcohol and next day about 10 to 15 episodes and which was non bilious initially and bilious there after and non projectile and contents as food particles and there was sudden increase in pain of lower chest for which he came to our hospital and he was not taking any medication for diabetes since 10days He was given Zofer for vomitings and IV fluids were given and his sugar levels were 500-600mg/ dl he was put on Insulin for first 2 days he was normal then he developed itching all over the body but they continued insulin for next 2 days then he had severe itching all over the body ( avil was given) so insulin was stopped and was shifted to oral medication glimiperide 4mg morning , metformin 500 mg morning and glimiperide - 3 mg , metformin 500 mg night. He want' s go to de - addiction centre but his sugar levels are not controlled so he was sent back to maintain normal sugar levels and to be on oral medication.

Past history

▪ Known case of diabetes since 8 years 

▪No history of hypertension, asthma, epilepsy, CAD

Family history

 Not significant

Personal history 

 Diet- mixed

Appetite- normal ( does not take food when he consumes alcohol )

Sleep- inadequate( when he does not take alcohol)

Bowel and bladder movements- regular

Habits- consumes alcohol from 2009 occasionally but from 2019 consumed daily , smokes while drinking about half packet each time

General examination

 Patient was conscious , coherent, cooperative well oriented to time , place person 

He is thin built and moderately nourished

Pallor- mild

icterus- absent

cyanosis- absent

clubbing- absent

Lymphadenopathy - absent

Edema- absent

VITALS-

Temp: 98°F

PR: 78bpm

RR: 18 cpm

BP: 120/80 mm hg

SpO2: 98% on RA

 GRBS- 

 • 15/3/2022- 500 to 600 mg/dl

•16/3/2022

 2AM (16/3/22): 101mg/dl 

6AM (16/3/22): 97 mg/dl

8 AM ( 16/3/22): 144 mg/dl

•18/03/2021

 8am- 323mg/dl

10am- 259 mg/ dl

1pm- 251mg/ dl

3pm- 245 mg /dl 

7pm -245 mg/ dl

•22/3/2022

8am -310 mg /dl

10am - 277mg/ dl

•24/3/2022

4 am- 171 mg/dl

7am -341 mg/dl

10am- 250 mg/dl

11am -166 mg/dl

3pm- 341 mg/dl 

•25/ 3 /2022

4am -171g/dl

7am -341 mg/dl

1pm- 209 mg/dl

7pm -166 mg/dl

10 pm- 209mg/dl

•26/ 3/2022

7am - 166 mg/dl

10am- 304 mg/dl

3pm- 296mg/dl

7 pm -201mg/dl

10pm- 269mg/dl

•27/ 3/ 2022

6 am- 271 mg/dl

8am- 169 mg/dl

10am-- 306 mg/dl

2pm- 117 mg/dl

Systemic examination

▪CVS-- s1 ,s2 heard no murmurs

 • Respiratory system- normal vesicular breath sounds heard

 • Abdomen- no tenderness no. . palpable mass , not distended

▪CNS-

 -Patient is conscious

-Speech -normal

-No signs of meningeal irritation

-SENSORY EXAMINATION,- touch, pain , vibration present

-No muscle wasting seen

-Tone of muscles is normal

▪REFLEXS:-

 

• Deep tendon reflexes

                        Right.                Left

  Knee jerk. +2.                          +2

  Ankle reflex +2                        +2    

  Biceps. +2.                               +2      

  Triceps. +2                               +2

  Supinator. +2.                          +2    

  

•Power

 

Biceps. 5/5.                               5/5

Triceps. 5/5.                              5/5

Extensors of knee

                       5/5.                       5/5

 Flexors of knee

                     5/5.                          5/5

Exetnsors of hip

                      5/5.                          5/5

Flexors of hip

                     5/5.                           5/5

•Gait -normal

▪Coordination

- Finger nose test-able to perform

- knee heel test- able to operform

- Romberg sign- negative

Investigation

 

 ▪ 15/3/2022

 S. Lipase: 48 IU/L

S. Amylase: 74 IU/L

Urine for ketone bodies: negative 

•LFT: 

TB: 1.08

DB: 0.24

AST: 18

ALT: 10

Alk P: 242

TP: 7.3

Alb: 4

A/G: 1.23

•ABG:

     

USG ABDOMEN

 

 

• Chest x ray AP view

• ECG

Serum creatinine: 1.0

Serum urea: 15

•Hemogram: 

Hb: 10.5

TLC: 5,400

N:65

L: 28

PLT: 2.30

 •Electrolytes

Na: 138

K: 4.1

Cl: 99

▪ 17/03/2022

Hba1c- 8.1

Provisional diagnosis

 •Uncontrolled sugars with diabetic foot ulcer and neuropathy

•RTA with left 11th rib fracture , alcohol dependency

. Recurrent pancreatitis

Treatment

  

Tab - Glimeperide 4mg morning

Tab - Glimiperide 3mg night 

Tab - Metformin 500mg bd

Tab - Pan 40 mg

Tab - Dolo 650 mg

Tab-Ultraset 1/2 tab QID