PATIENT WITH C/O DIFFICULTY IN BREATHING, HARD STOOLS , BLOATING OF ABDOMEN , GIDDINESS

 Case History and Clinical Findings

CHIEF COMPLAINTS :

DIFICULTY IN BREATHING SINCE 2 MONTHS, HARD STOOLS SINCE 1MONTH , BLOATING OF ABDOMEN SINCE 1MONTH , GIDDINESS SINCE 1 WEEK

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS BACK THEN HE DEVELOPED DIFFICULTY IN BREATHING WHICH IS OF GRADE 2 WITH NO AGGREVATING AND RELEIVING FACTORS

COMPLAINTS OF HARD PELLET STOOLS WITHOUT ANY BLOOD TINGE SINCE 1 MONTH

C/O BLOATING OF ABDOMEN SINCE 1 MONTH

N/H/O CHEST TIGHTNESS

N/H/O ORTHOPNEA PND

N/H/O BLEEDING MANIFESTATIONS

PAST HISTORY :

K/C/O HYPERTENSIOPN ON TAB.CINOD 10 MG BD SINCE 10 YEARS

K/C/O DM SINCE 30 YEARS ON INJ.HAI 8-10-8

K/C/O CKD SINCE 13 YEARS ON NODOSIS 500 MG


PERSONAL HISTORY:

DIET: MIXED

APPETITE: NORMAL

BOWEL AND BLADDER MOVEMENTS: REGULAR.

NO KNOWN ALLERGIES AND ADDICTIONS.

FAMILY HISTORY: NOT SIGNIFICANT.

GENEREAL EXAMINATION:

PATIENT IS C/C/C

TEMP: AFEBRILE

PR: 80 BPM

RR: 20 CPM

BP: 110/70 MMHG

SPO2: 98 @ RA.

SYSTEMIC EXAMINATION:

CVS: S1 S2 HEARD. NO MURMURS

RESPIRATORY SYSTEM: BAE+

P/A- SOFT, NON TENDER.

CNS- NO FOCAL NEUROLOGICAL DEFECTS.

OPTHALMOLOGY REFERRAL ON 20/5/24 I/V/O FUNDOSCOPIC EXAMINATION.

NO EVIDENCE OF DIABETIC OR HYPERTEMDOVE RETINOPATHY CHANGES.

COURSE IN HOSPITAL:

A 75 YEAR OLD MALE CAME WITHDIFICULTY IN BREATHING SINCE 2 MONTHS, HARD STOOLS SINCE 1MONTH , BLOATING OF ABDOMEN SINCE 1MONTH , GIDDINESS SINCE 1 WEEK.

PATIENT WAS DIAGNOSED AS ACUTE GASTRITIS K/C/O DIABETES MILLETUS SINCE 30 YEARS K/C/O HYPERTENSION SINCE 10 YEARS, CHRONIC KIDNEY DISEASE STAGE 4.

ALL THE NECESSARY INVESTIGATION WHERE SENT.

OPTHALMOLOGY REFERRAL ON 20/5/24 I/V/O FUNDOSCOPIC EXAMINATION.

NO EVIDENCE OF DIABETIC OR HYPERTEMDOVE RETINOPATHY CHANGES.

PATIENT TREATED CONSERVATIVELY AND ACCORDINGLY.

PATIENT SYMPTOMS SUBSIDED.

PATIENT DISCHARGED IN HEMODYNAMICALLY STABLE STATE.


PROVISIONAL DIAGNOSIS :-

ACUTE GASTRITIS

K/C/O DIABETES MILLETUS SINCE 30 YEARS

K/C/O HYPERTENSION SINCE 10 YEARS

CHRONIC KIDNEY DISEASE STAGE 4


Investigation:-

RFT 18-05-2024 03:46:PM:-

 UREA39 mg/dl50-17 mg/dl

CREATININE2.4 mg/dl1.3-0.8 mg/dl

URIC ACID4.4 mmol/L7.2-3.5 mmol/L

CALCIUM9.8 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS3.1 mg/dl4.5-2.5 mg/dl

SODIUM139 mmol/L145-136 mmol/L

POTASSIUM4.3 mmol/L.5.1-3.5 mmol/L.

CHLORIDE105 mmol/L98-107 mmol/L

LIVER FUNCTION TEST (LFT) 18-05-2024 03:46:PM :-

Total Bilurubin0.59 mg/dl1-0 mg/dl

Direct Bilurubin0.14 mg/dl0.2-0.0 mg/dl

SGOT(AST)27 IU/L35-0 IU/L

SGPT(ALT)16 IU/L45-0 IU/L

ALKALINE PHOSPHATASE162 IU/L119-56 IU/L

TOTAL PROTEINS6.6 gm/dl8.3-6.4 gm/dl

ALBUMIN4.08 gm/dl4.6-3.2 gm/dl

A/G RATIO1.62

COMPLETE URINE EXAMINATION (CUE) 18-05-2024 03:46:PM:-

 COLOUR-Paleyellow

APPEARANCEClear

REACTIONAcidic

SP.GRAVITY1.010

ALBUMIN - Trace

SUGAR- Nil

BILE SALTS-Nil

BILE PIGMENTS-Nil

PUS CELLS -3-4

EPITHELIAL CELLS -2-3

RED BLOOD CELLS-Nil

CRYSTALS-Nil

CASTS-Nil

AMORPHOUS DEPOSITS-Absent

OTHERS-Nil

HBsAg-RAPID-18- 05-2024 03:46:PM-Negative 

Anti HCV Antibodies - RAPID18-05-2024 03:46:PM:-Non Reactive

hba1c: 6.6%


Treatment Given:-

1. INJ HAI SC/ TID 4U-6U -4U

2. TAB NODOSIS 500 MG PO/OD 0-1-0

3. TAB ECOSPRIN-A 5/10 PO/HS 0-0-1

4. TAB DYTOR PLUS 10/25 PO/OD @ 10 AM

5. TAB CINOD 10 MG PO/BD 1-0-1 .

6. SYP CREMAFFIN 20 ML PO/HS 0-0-1

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