65 year old male patient

 GM Blog: 65 year old male patient 


NOTE
This is an ongoing case and will be updated 
The reference link (if any) will be mentioned at the bottom.

Date of admission: 6-10-2022

CHIEF COMPLAINT: Vomiting and fever since four days. Loose Stools since three days.

HISTORY OF PRESENT ILLNESS-
 
Patient was apparently asymptomatic 5 days back. Then he had vomiting immediately after eating comprising of food and water depending on what he consumed. Then he came to the hospital on the same day.
He had 4-5 episodes of vomiting in a day.
times that day which was associated with squeezing type of pain in the epigastric region and developed a high grade fever. He also had associated shortness of breath. He came to this hospital on the same day, was medicated for it and discharged the next day.
The symptoms, however, did not subside and the patient was rushed to the ICU at 4pm on 9.10.2022 with complaints of vomiting and not being able to consume anything without vomiting. He hasn't been passing any stools till 9:30am yesterday.


PAST HISTORY:

Known case of Hypertension since 8 yrs, Diabetis mellitus type 2 since 8 yr, Asthma since 6 months

Not known case of Tuberculosis,leprosy, Cardiovascular diseases,chornic kidney disease and any other chronic illness.

He has been having joint pains since 10 years and has been going to the hospital repeatedly for his pains. He took painkillers and continued to work everyday till 4 days ago.

From 3 years ago, the patient has been getting scaly, itchy rashes with peeling of skin on his arms and legs. He was told this was due to diabetes.

PERSONAL HISTORY:
Married 
Tractor driver 
Diet: mixed. ( Non vegetarian)
Built-well built (obese)
Appetite -decreased
Bladder movment-normal
Bowel movements- irregular
Allergy-generalised itching
Addiction-alcoholic 38 yrs ago,chew betel leaf and Tobacco regularly but stopped 5 days ago.


FAMILY HISTORY:
Not significant 

GENERAL EXAMINATION:
Patient is conscious, coherent, co-operative.
He is well oriented to time, place and person. 
He is well built and nourished  
Pallor - absent
icterus absent
No cyanosis
No clubbing
No Edema 
No Lymphadenopathy 

VITALS :  
Temperature: 98.6°F
Blood pressure: 100/60 at time of admission 
Pulse rate: 84bpm
Respiratory rate: 20/min
Spo2: 98%
GRBS: 121mg%
The swelling on the dorsum of his left hand is 4×5 cm in size, elliptical, firm, non-reducible. Slip test is positive.


SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM :  
S1 and S2 heard, no murmurs heard 

RESPIRATORY SYSTEM : 
Shape of chest: normal
Position of trachea: central
dyspnoea absent
Breath sound : vesicular 


CNS : 
Level of consciousness: alert
Speech: normal
Glasgow coma scale: 15/15 f4v5m6


ABDOMINAL EXAMINATION:
Distended, umbilicus central and everted 
,non tender 
,Soft
,No palpable mass
Tenderness in the right hypochondrial and epigastric regions. 
Liver is palpable.








Investigation reports 

2D ECHO


ECG



Provisional diagnosis: acute gastroenteritis

Treatment: 


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