General medicine case

  GM CASE

11/10/22

V.Divyasree 

Roll no.- 142

Below is an E-log describing patient centered data approach and discussion regarding patient de- identified health data.

CHIEF COMPLAINTS

  • A 65 year old male driver(tractor) by occupation came to the OPD with complaints of Vomiting and fever since four days. Loose Stools since three days.
  • Admitted on 6/10/22

HISTORY OF PRESENT ILLNESS-
 
  • Patient was apparently asymptomatic 5 days back. Then he had vomitings after eating any food or even after drinking water. 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 10/10/22.
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:


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 
  • There is a swelling on the dorsum of his left hand is 4×5 cm in size, elliptical, firm, non-reducible. Slip test is positive







VITALS :  
  • Temperature: 98.6°F
  • Blood pressure: 100/60 at time of admission 
  • Pulse rate: 84bpm
  • Respiratory rate: 20/min
  • Spo2: 98%
  • GRBS: 121mg%
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.

Investigations 









Provisional diagnosis:

  • acute gastroenteritis

Treatment: 






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