Final pratical exam long case





Feb 8,2022

A 50 year male farmer brought  to casualty with chief complaints of 

-pain abdomen since15 days

-Loss of appetite since 10 days

-H/o fever since 3days.

-h/o vomitings since 3 days

-h/o constipation since 3 days

-h/o altered sensorium since 3 days

-h/o yellowish discoloration of urine since 2 days.

HISTORY OF PRESENTING ILLNESS -

Patient was apparently asymptomatic 15 days ago,

he is a chronic smoker and daily alcohol consumption from past 35 yrs.

 he developed pain abdomen in epigastric region from past 15 days, associated with 3 episodes of vomitings-food particles as content. With severe abdominal pain at lower part

Patient also suffered with constipation from past 3 days.

From past 3 days he developed altered sensorium.

Yellowish discolouration in urine is seen from past 2 days.



PAST HISTORY - 


Not a K/C/O DM, HTN,CVA,CAD,COVID-19.

DIAGNOSED AS DENGUE IgM POSITIVE ON 2/2/22-AND TREATMENT  TAKEN

PERSONAL HISTORY :

DIET - MIXED,

APPETITE -LOSS OF APPETITE SINCE 10 DAYS

BOWEL - CONSTIPATION SINCE 3 DAYS

BLADDER - REGULAR, ADDICTIONS-H/O  SMOKING 35yrs ago(2-3per day)- 

ALCOHOL-REGULAR INTAKE OF 90ML  SINCE 35YRS.


FAMILY HISTORY:Non-significant.

Allergic history:not known case of allergy 

Not allergic to pollen ,and any known drugs


TREATMENT HISTORY: NON SIGNIFICANT 


 ON EXAMINATION -


PATIENT IS DROWSY , NO CONSCIOUS , NON COOPERATIVE

ICTRUS -PRESENT

 NO PALLOR

CLUBBING:ABSENT 

 NO  CYANOSIS , 

NO LYMPHADENOPATHY, 

NO  EDEMA


VITALS - 


TEMPERATURE - 102°F

 

PULSE RATE - 98°BPM

BLOOD PRESSURE - 130/80 MM OF HG 

RESPIRATORY RATE - 22

SPO2 - 98% AT ROOM 

SYSTEMIC EXAMINATION - 


CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS


RESPIRATORY SYSTEM : 

BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS



P/A - soft,non tenderness 

, no organomegaly



CNS: 

Pt is DROWSY,NO RESPONSE,

non cooperative       

INVESIGATION:

PROVISIONAL DIAGNOSIS: Fever with altered sensorium secondary to viral encephalopathy?

TREATMENT:

1.IVF-NS,RL@100ML /HR

2.INJ.MONOCEF 1 GM /IV/BD

3.INJ.ZOFER 4MG/IV/TID

4.INJ.THIAMINE 2 AMP IN 100ML NS/IV/STAT

5.INJ.NEOMOL 1 GM/IV/STAT

6.TAB.PCM 650MG/PO/TID

7.SYP.LACTULOSE 20ML/PO/TID

8.PROCTOLYTIC ENEMA-P/R-TWICE DAILY

9.INJ.DOXYCYCLIN E 100MG/IV/BD

10.INJ.VIT K 10MG IV_OD

11.INJ.PAN 40 MG /IV/BD


Comments

Post a Comment

Popular posts from this blog

Short case final general medicine

Image
  Date of Admission- 05 -02-22 A 25 year old Male presented to OPD with chief complaints of  vomitings 10 episodes and bipedal edema and decreased Urinary output since 3 years .  HISTORY OF PRESENT ILLNESS Patient was apparently asymptomatic 3 years ago then  he developed multiple episodes of vomitings for which he was admitted in the hospital and found to have high BP of 170 mm Hg .  HISTORY OF PAST ILLNESS  Known history of hypertension . Known history of Tuberculosis  No history of Diabetes mellitus asthma, epilepsy. No history of surgeries, chemotherapy or radiotherapy  PERSONAL HISTORY  Diet - Mixed   Appetite- Normal  Bowel movement is regular . Micturition - Normal  Addictions- None  Sleep  - Regular  FAMILY HISTORY   No history of DM, CAD, Asthma and thyroid disorders in the family GENRAL EXAMINATION  Patient is conscious, coherent, co-operative. There are no signs of icterus, clubbing, pallor, cynosis, lymphadenopathy VITALS Temperature- 98.4   Pulse rate-  78 bpm Respiratory
Read more
Image
A 56 year male  patient workers in food center presented to opd with complain of swelling in leg and abdomen since 7 days ago. History of present illness: Patient was apparently asympmatic one month back .he then developed swelling in legs with no pain.they is gradually increase in swelling from legs to abdomen after 2 days . Patient develops pedal edema of pitting type grade -1 . After 10 days it is progressed to grade -2 Over 15 days pitting type grade 3 Patient has no complaints on fever, vomiting . Past history: 1.Patient is suffering with hypertension since 3 month .he is undergoing into medication immediately  2.no diabetes, no seizures,no epilepsy,no tuberculosis,no thyroid disorder  3.patient had not undergone any surgeries  4.patient had suffered from pulmonary koch’s 22 yrs back .patient has used ATT for 6 months. Personal history:  1.diet- mixed  2.appetite- normal  3 .bowel amd bladder movement- normal  4 . Sleep- normal  5. Addictions - no smoking and no alcohol consumptio
Read more