202313701

 

 

 


Case History and Clinical Findings C/O FEVER SINCE 15 DAYS ABDOMINAL PAIN SINCCE 15 DAYS VOMITINGS SINCE 15 DAYS

HOPI :

PATIENT WAS APPARENTLY ASYMTOMATIC 3 MONTHS BACK THEN SHE HAD BURNING MICTURAION, FROTHY URINE,URGENCY,POLYURIA,NOCTURIA

NO H/O POLYDIPSIA

COMPLAINTS OF FEVER SINCE 15 DAYS, INTERMITTENT, LOW GRADE,ASSOCIATED WITH CHILLS AND RIGORS, RELIEVED BY TAKING MEDICATION

 

EPIGASTRIC PAIN SINCE 15 DAS, SQUEEZING TYPE, TENDERNESS PRESENT, NO GUARDING, NO RIGIDITY, ASSOCISTED WITH VOMITINGS,FOOD AS CONTENT, NON PROJECTILE,NON BILIOUS,NON FOUL SMELLING, 3-4 EPISODE OF BLACK COLOURED VOMITTINGS

NO LOOSE STOOLS, NO CHEST PAIN,PALPITATIONS, COUGH, COLD PAST HISTORY ;

H/O OF SPLIT SKIN GRAFT FOR RIGHT DIABETIC FOOT FOR 4 YEARS BACK H/O LEFT BELOW KNWW AMPUTATION 1 YEAR BACK

H/O HYSTERECTOMY

K/C/O TB 5 YEARS BACK, DM SINCE 20 YEARS ON MIXTARD INSULIN 20 UNITS, HYPERTENSION SINCE 1 YEAR ON TAB TELMA 40 AND AMLO 5MG PO/OD,

H/O BLOOD TRANSFUSION OF 8 UNITS PERSONAL HISTORY

LOSS OF APPETITE SINCE 1 MONTH FAMILY HISTORY ;

MOTHER K/C/O DM 2 GERNERAL EXAMINATION

O/E: PATIENT IS CONSCIOUS AND COHERENT

NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY VITALS

TEMP:96.8F PR:82 BPM RR:42 CPM

BP:140/80 MM HG GRBS: 199 MG/DL

CVS: S1 S2 HEARD , NO MURMURS

RS: BAE PRESENT , NO ADDED SOUNDS P/A: SOFT, NON TENDER

CNS: NFND

 

 

Investigation

HEMOGRAM

 

 

27/03/23

 

HB 8.9

TLC 19300

PLATELET COUNT 5.48 28/03/23

HB 7.6

TLC 13900

PCV 2.88

RBC 2.88

PLATELET COUNT 4.2

 

 

30/03/23

HB 6.8

TLC 12100

RBC 2.57

PLATELET COUNT 4.18

 

 

31/03/23

HB 6.5

TLC 9800

RBC 25

PLATEL;ET COUNT 3.93

 

 

01/04/23

 

 

HB 6.8

TLC 9900

RBC 2.63

PLATELET COUNT 4.0

 

 

02/04//23

 

 

HB 7.4

TLC 11300

 

PCV 24

RBC 2.83

PLATELET COUNT 4.16

 

 

ULTRASOUND

 

 

GALL BLADDER ; 4MM CALCULUS NOTED

RIGHT KIDNEY; 4MM CALCULUS NOTED IN THE UPPER POLE ECHOTEXTURE INCREASED

LEFT KIDNEY ; FEW CALCULI NOTED

LARGEST SIZE 8MM CALCULUS NOTED IN THE MIDPOLE ECHOTEXTURE INCREASED

FINAL IMPRESSION ; CHOLELITHIASIS BILATERAL RENAL CALICULI BILATERAL GRADE 1

 

DOPPLER ;

EF 45 PERCENT

IVC 0.77CM COLLAPSING RVSP 30MM Hg

TRIVIAL AR/MR/TR

RWMA LAD HYPOKINETIC NO AS/MS MODERATE LV DYSFUNCTION DIASTOLIC DYSFUNCTION,NO PAH/PH

UPPER GI ENDOSCOPY - MILD DISTAL ESOPHAGITIS , DEEP EXCAVATED ULCER ABOUT 2X2 CM WITH ACID HEMATIN AT BASE , ANOTHER TWO SMALL ULCER , MULTIPLE GASTRODUODENAL ULCERS WITH SRH , NSAID INDUCED

NCCT ABDOMEN:

Treatment Given(Enter only Generic Name)

1. IV FLUIDS NS,1DNS,1RL 2 75ML 2.INJ MONOCEF 1GM IV/BD

3. INJ TRAMADOL

4.  INJ PAN 80MG IN 100ML NS IV/BD 5.INJ ZOFER 4MG IV/SOS

 

6. INJ LASIX 40MG IV/OD 7.T.CINOD 10MG PO/OD 8.T.MET-XL 25MG PO/OD

9.  T.ECOSPORIN AV 75/10 PO H/S

10.  SYP. SUCRALATE 10ML PO/TID

Advice at Discharge

INJ HUMAN ACTRAPID INSULIN 10 UNITS S/C TID BBF TAB AGUMENTIN 625MG PO/TID X 5 DAYS

TAB ULTRACET PO/OD SOSX 5 DAYS TAB PAN 40MG PO/ODX 5 DAYS

TAB ZOFER 4MG PO/SOS X 5 DAYS TAB LASIX 40MG PO/OD

T.CINOD 10MG PO/OD T.ECOSPORIN AV 75/10 PO H/S

SYP. SUCRALATE 10ML PO/TID 10 MIN BEFORE FOOD


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