General medicine case 7

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs

A 60 yr old female presented to opd with chief complaints of vomiting since 20 days fever since 2 - 3 days abdominal pain since 2- 3days

HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 20 days back then she had 4-5 episodes of vomiting which is non projectile and non bilious non blood tinged and had fever 2-3 days back and abdominal pain since 2 -3 days 

Patient also gives history of joint pains she is unable to walk

HISTORY OF PAST ILLNESS
Patient gives the history of pedal edema went to local hospital 4 months back where she was diagnosed as Acute kidney injury which relieved on medication.
Hypertension since 1 and half yr and on medication
No history of diabetes mellitus and asthma

PERSONAL HISTORY
Patient takes mixed diet 
 Loss of appetite 
Sleep is adequate
Bowel and bladder movements are regular
Patient does not having habits like consuming alcohol and smoking

GENERAL PHYSICAL EXAMINATION
Patient is conscious coherant and cooperative and well oriented to time place and person she well built
Pallor present
No icterus
No clubbing
No pedal edema
No generalized lymphadenopathy

VITALS
Temperature- afebrile
Blood pressure -110/70mmHg
Respiratory rate 12cycles
Pulse rate 72 bpm
Spo2- 98% room air

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Inspection: 

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation:

JVP - normal

Apex beat : felt in the left 5th intercostal space

In midclavicular line 

Ausculation:

S1 ,S2 Heard


RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea- central

Normal vesicular breath sounds - heard

No added sounds


PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

Swelling in the knee joint because of which she is unable to walk 




 
Patient gave history of some blister formation that was due to infection which relieved on medication

INVESTIGATIONS
ECG
ESR


LFT




 

DIAGNOSIS
Peptic disease with severe duodenitis

TREATMENT
IV fluids 2 units NS 1 unit RL at 100 ml/hr
Inj pantop 500 ml
Inj zofer 4mg IV/ TID
Monitoring vitals 

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