25November 2021
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A 60 yr old female presented to the opd with chief complaints of vomiting since 20 days fever since 2 - 3 days abdominal pain from 2- 3days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 20 days back then she had 4-5 episodes of vomiting and had fever 2-3 days back and abdominal pain since 2 -3 days.Patient also gives history of joint pains due to which she is experiencing difficulty during walking.
HISTORY OF PAST ILLNESS
Patient gives the history of pedal edema for which attended to local hospital 4 months back where she was diagnosed as Acute kidney injury which relieved on medication and was advised Dialysis by the local RMP doctor.Patient also explained about shortness of breath on walking SOB-IV
Hypertension since 1 and half yr and on medication
No history of diabetes mellitus and asthma
PERSONAL HISTORY
Mixed diet
Loss of appetite
Sleep is adequate
Bowel and bladder movements are regular
Patient does not having habits like consuming alcohol and smoking
Menstrual history: menarche at the age of 12yrs and menopause at 50yrs
TREATMENT HISTORY: No previous surgeries and no h/o drug allergy
GENERAL PHYSICAL EXAMINATION
Patient is conscious coherent and cooperative and well oriented to time place and person she well built
Pallor present
No icterus
No clubbing
pedal edema
No generalized lymphadenopathy
VITALS
Temperature- afebrile
Blood pressure -110/70mmHg
Respiratory rate 12cyclesperminute
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 mid clavicular line
Auscultation:
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 experiencing difficulty to walk since 2yrs
Patient gave history of some blister formation that was due to infection which relieved on medication few years earlier
INVESTIGATIONS
ECG
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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