202317808

 

 

 

Case History and Clinical Findings

PATIENT WAS BROUGHT TO THE CASUALITY WITH COMPLAINTS OF PAIN ABDOMEN AND VOMITINGS SINCE 23-4-23 4PM

 

HOPI-

PATIENT WAS APPARENTLY NORMAL UNTIL 23-4-23 4PM SINCE THEN SHE DEVELOPED PAIN ABDOMENWHICH IS INSIDIOUS IN ONSET ,GRADUALLY PROGRESSIVE ,SQUEEZING TYPE OF PAIN

ASSOCIATD WITH VOMITINGS WHICH ARE 2 EPISODES ,NON PROJECTILE,MUCOID,WITH FOOD PARTICLES AS CONTENT

H/O NAUSEA PRESENT,SHORTNESS OF BREATH PRESENT GRADE-2

H/O FEVER SINCE 1 DAY HIGH GRADE ,INTERMITTENT,NOT ASSOCIATED WITH CHILLS AND RIGORS,RELIEVED BY MEDICATION

 

PAST HISTORY-

K/C/O DIABETES MELLITUS T-2 SINCE 20 YRS AN DON MEDICATION[UNKNOWN]

 

N/K/C/O HTN,TUBERCULOSIS,EPILEPSY,CVA,CAD,THYROID DISORDERS

 

 

PERSONAL HISTORY- DIET: MIXED APPETTITE:NORMAL

BOWEL AND BLADDER: REGULAR SLEEP: ADEQUATE

NO ADDICTIONS

 

 

GENERAL EXAMINATION-PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE WELL ORIENTED TO TIME,PLACE,PERSON

MODERATLY BUILT AND NOURISHED

 

 

VITALS-

TEMPERATURE-AFEBRILE PR-88BPM

BP-130/70 RR-18CPM

 

SYSTEMIC EXAMINATION-

CVS-S1S2 HEARD,NO MURMURS RS-BAE+,NVBS HEARD

CNS-NFND,HMF INTACT

P/A-SOFT,NON TENDER,NO ORGANOMEGALY

Investigation

ECG-NORMAL SINUS RHYTM

ULTRASOUND-NO ABNORMALITY DETECTED HAEMOGRAM

24/4/23

HB 8.9

TLC 30,500

NEUTROPHILS 89

LYMPHOCYTE 06

 

PCV 31

MCV 91.4

MCH 26.3

MCHC 28.7

RBC 3.3 MILLION/CUMM PLT 3.1LAKHS/CUMM

Treatment Given(Enter only Generic Name)

SOFT DIET

IV FLUIDS NS@75ML/HOUR INJ.PIPTAZ 4.25GM /IV/BD INJ.PAN 40 MG/IV/OD

INJ.ZOFER 4 MG/IV/SOS

INJ.HAI S/C TID[BEFORE MEALS] INJ.NPH S/C BD [BEFPRE MEALS] T.PCM 650MG/PO/TID

GRBS 7POINT PROFILE MONITORING BP MONITORING 2ND HOURLY STRICT I/O CHARTING

SYP.ASCORIL-D 2.5ML/PO/TID

SYP.CITRALKA 10ML/PO/TID IN 1 GLASS OF WATER

Advice at Discharge

1. STRICT DIABETIC DIET

2.  PAN D 40 MG PO OD BBF

3. STRICT GRBS MONITORING BEFORE AND AFTER 2 HRS OF FOOD


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