short case
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Systemic examination:
A 53 yr old male patient came to casualty with a cheif complaint of :
Fever,abdominalpain , abdominal discomfort, bloating ,constipation and no passage of stools since 4 days.
History of present illness:
Patient was apparently asymptomatic 4 days back then he developed high grade fever which is intermittent associated with chills and rigors, headache and constipation.
Patient also complaints of abdominal pain (dull aching insicidous onset) and bloating since 4 days .
Had single episode of vomiting on 19th Jan 8pm( approximately).
C/o loss of appetite,pedal edema(pitting,bilateral , extending till knees)and facial puffiness
H/o burning micturation since 4 days ,shortness of breath
The symptoms are relieved by medication and fluid intake and no apparent aggravating factors.
Past history:
Patient has Diabetes mellitus 2 since 10yrs and is on metformin(500mg) plus glimipiride(100mg).
Patient had CAD and had PTCA done 4 years back.
Not a k/c/o Hypertension, Asthma, epilepsy, CKD,TB
Past history of medication:
Used blood thinning agents for the case of PTCA and discontinued abruptly on his own.
Personal history:
Diet:mixed
Appetite:loss of appetite
Sleep:Adequate
Micturation:burning
Bowel &bladder movements: decreased (since 4 days)
Family history:
No history of similar complaints in the family.
Allergies:
No known history of drug allergy
Addictions:
Daily alcoholic since 20 years
Used to smoke 2 packs of cigarette daily before 4 years( for 25 yrs)
Stopped smoking 4 yrs back
General examination:
Patient is conscious, coherent, cooperative and well oriented to time, place
Moderately built and moderately nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy.
Pedal edema (bilateral,pitting type)
Vitals:
Temp- 101°F
BP-140/80MMHG
RR-18CPM
PR- 92BPM.
GRBS-167mg/dl.
Spo2 - 97%
ABDOMEN:
Shape distended
Flanks:free
Umbilicus: central &inverted
no scars and sinuses over the skin
No engorged veins
Movements are normal
No visible pulsations
Cullen's sign-negative
Gray turner's sign-negative
PALPATION:
no local raise of temperature
no tenderness
Kidney liver spleen not palpable
no palpable mass
PERCUSSION:
No fluid thrill
No Shifting dullness seen
AUSCULTATION:
bowel sounds heard
No bruit
RESPIRATORY:
INSPECTION:
Chest: symmetrical
Trachea: central
No drooping of shoulders,
no supraclavicular hollowing
no use of accessory respiratory muscles
Movement with respiration is symmetrical on both sides
PALPATION:
trachea: central
no intercoastal widening
Whole thorax measurement:34 inches
Hemi Thorax:17 inches
Vocal fremitus -normal
PERCUSSION:
Dullness noted from 5th intercoastal space
AUSCULTATION:
vesicular breath sounds
No added sounds
CVS:
S1&S2 heard
No thrills,no murmurs
CNS:
Concious
Speech:normal
Gait: normal
No signs of neck stiffness
Sensory system :normal
Motor system: normal
Investigations:
Diagnosis:
Viral pyrexia , thrombocytopenia ,
Type 2 Diabetes Mellitus
Treatment:
Inj pan 40mg IV /OD
Inj optineuron 1 amp M100ml NS IV/OD
Inj Thiamine 200 mg M 100ml NS IV/BD
Inj lasix 40mg IV / BD
Tab dolo 650mg
Grbs profile monitoring
Fluid restriction to <1 lit per day
Monitoring vitals
