55 year old male with abdominal discomfort since 3days, involuntary movements 1episode since 1 day

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I have 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 diagnosis and treatment plan.
    55 year old male, Resident of miryalaguda came to casualty  with chief complaints of 
   •Abdominal discomfort since 3 days 
   •Involuntary movements 1episode yesterday night followed by loss of consciousness and excessive sweating, giddiness since yesterday evening 
HISTORY OF PRESENTING ILLNESS:
    Patient was apparently asymptomatic 3days back then he developed abdominal discomfort since 3 days associated with belching and indigestion, insidious in onset 
     Patient had one episode of involuntary movements followed by loss of consciousness
     Patient was initially taken to local hospital where INJ 25 D was given and was referred to our hospital 
     H/o weight loss present 
PAST HISTORY:  Not a k/c/o DM, HTN , Epilepsy 
Known Alcoholic and smoker -Abstained from alcohol since a week 

PERSONAL HISTORY:
Diet- regular
Appetite - Normal
Bowel and bladder movement- regular
Addictions- alcoholic and smoker since 20 years 

FAMILY HISTORY:
Not significant 

GENERAL EXAMINATION:
Patient is  conscious,coherent, co operative 
Oriented to time ,Place, Person 
VITALS :
BP: 90/70mm hg
PR: 100 bpm
GRBS : 42 mg/dL
RR: 18cpm 

PER ABDOMEN EXAMINATION:
Tenderness present in Epigastrium, Left hypochondrium 
Bowel sounds present 

CARDIOVASCULAR SYSTEM:
S1, S2 heard

RESPIRATORY SYSTEM:
BAE present, NVBS 

CNS :NAD 

INVESTIGATIONS:
Hemogram:
Hb 8.7
TLC 10,400
Platelet count 1.40
N/L/M/E/B 85/05/08/02/00

LFT:
Tb 0.40
DB 0.20
SGOT 51
ALP 272
TP 4.9
Alb 2.84
A/G 1.38

RFT:
Urea 54
Creat 2.5
Sodium 133
Potassium 4.3
Chloride 98

RBS : 163 

CHEST X RAY :
Multiple well defined radio opacities in B/L lung fields likely metastases 
RIGHT hila is widened 





USG ABDOMEN :
E/O multiple hypoechoic well defined lesions in both lobes of liver largest measuring 33X34mm in segment 4A and 8, likely multiple liver abscess 
B/L Grade 2RPD 
6mm calculi noted in left kidney 
Right VUJ is dilated 



DIAGNOSIS :
?Hypoglycemia secondary to malignancy 
? Primary with lung and liver mets  

DOA: 24/04/22

SOAP NOTES ICU BED 5 DAY 2:

S 

No fresh complaints 


O

GENERAL EXAMINATION:

Patient is  conscious,coherent, co operative 

Oriented to time ,Place, Person 

VITALS :

BP: 90/70mm hg

PR: 100 bpm

GRBS : 42 mg/dL

RR: 18cpm 


PER ABDOMEN EXAMINATION:

Tenderness present in Epigastrium, Left hypochondrium 

Bowel sounds present 


CARDIOVASCULAR SYSTEM:

S1, S2 heard


RESPIRATORY SYSTEM:

BAE present, NVBS 


CNS :NAD 


INVESTIGATIONS:

Hemogram:

Hb 8.7

TLC 10,400

Platelet count 1.40

N/L/M/E/B 85/05/08/02/00


LFT:

Tb 0.40

DB 0.20

SGOT 51

ALP 272

TP 4.9

Alb 2.84

A/G 1.38


RFT:

Urea 54

Creat 2.5

Sodium 133

Potassium 4.3

Chloride 98


RBS : 163 


CHEST X RAY :

Multiple well defined radio opacities in B/L lung fields likely metastases 

RIGHT hila is widened 






USG ABDOMEN :

E/O multiple hypoechoic well defined lesions in both lobes of liver largest measuring 33X34mm in segment 4A and 8, likely multiple liver abscess 

B/L Grade 2RPD 

6mm calculi noted in left kidney 

Right VUJ is dilated 

A

DIAGNOSIS :

?Hypoglycemia secondary to malignancy 

? Primary with lung and liver mets 

P

1)INJ 25D IV/stat 100ml/hr 

2)GRBS MONITORING HOURLY

3)VITALS MONITORING


DOA: 24/04/22

SOAP NOTES ICU BED1 DAY 3:


S 

Abdominal discomfort present since 5days 

 No other  complaints 


O

GENERAL EXAMINATION:

Patient is  conscious,coherent, co operative 

Oriented to time ,Place, Person 

VITALS :

BP: 110/70mm hg

PR: 95bpm

RR: 17cpm

GRBS :81


PER ABDOMEN EXAMINATION:

Soft , mild tenderness present all over the abdomen 

Bowel sounds present 


CARDIOVASCULAR SYSTEM:

S1, S2 heard


RESPIRATORY SYSTEM:

BAE present, NVBS 


CNS :NAD 


INVESTIGATIONS:

Hemogram:

Hb 8.7

TLC 10,400

Platelet count 1.40

N/L/M/E/B 85/05/08/02/00


RFT:

Urea 54

Creat 2.5

Sodium 133

Potassium 4.3

Chloride 98


RBS : 163 


A

DIAGNOSIS :

?Hypoglycemia secondary to malignancy 


P

1)INJ CEFTRIAXONE 1gm IV/BD 

2)INJ METROGYL 500mg IV/TID 

3)25D INFUSION ACCORDING TO GRBS LEVELS

4)TAB DOLO650mg PO/TID 

5)SYRUP ASCORYL 10ml TID 

6)Nebulisation with BUDICORT 8th hourly 

7)TAB SPOROLAC 2tablets TID 

8)GRBS MONITORING HOURLY

9)VITALS MONITORING

10)Plenty of oral fluids






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