ACUTE GASTRITIS K/C/O DIABETES MILLETUS SINCE 30 YEARS K/C/O HYPERTENSION SINCE 10 YEARS CHRONIC KIDNEY DISEASE STAGE 4

 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


NameValueRangeNameValueRangeRFT 18-05-2024 03:46:PM UREA39 mg/dl50-17 mg/dlCREATININE2.4 mg/dl1.3-0.8 mg/dlURIC ACID4.4 mmol/L7.2-3.5 mmol/LCALCIUM9.8 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.1 mg/dl4.5-2.5 mg/dlSODIUM139 mmol/L145-136 mmol/LPOTASSIUM4.3 mmol/L.5.1-3.5 mmol/L.CHLORIDE105 mmol/L98-107 mmol/LLIVER FUNCTION TEST (LFT) 18-05-2024 03:46:PM Total Bilurubin0.59 mg/dl1-0 mg/dlDirect Bilurubin0.14 mg/dl0.2-0.0 mg/dlSGOT(AST)27 IU/L35-0 IU/LSGPT(ALT)16 IU/L45-0 IU/LALKALINE PHOSPHATASE162 IU/L119-56 IU/LTOTAL PROTEINS6.6 gm/dl8.3-6.4 gm/dlALBUMIN4.08 gm/dl4.6-3.2 gm/dlA/G RATIO1.62COMPLETE URINE EXAMINATION (CUE) 18-05-2024 03:46:PM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINTraceSUGARNilBILE SALTSNilBILE PIGMENTSNilPUS CELLS3-4EPITHELIAL CELLS2-3RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilHBsAg-RAPID18- 05-2024 03:46:PMNegative Anti HCV Antibodies - RAPID18-05-2024 03:46:PMNon Reactive

hba1c: 6.6%

Treatment Given(Enter only Generic Name)

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

Advice at Discharge

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

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

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

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

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

6. SYP CREMAFFIN 20 ML PO/HS 0-0-1 X 7 DAYS.

Follow Up

FOLLOW UP TO GM OPD WITH FBS AND PLBS AFTER 2 WEEKS ON MONDAYS.

Comments

Post a Comment

Popular posts from this blog

60 year old male with loss of consciousness

Image
 A 60 years old male patient came to casuality with loss of consciousness at 2 Am  HOPI :  Patient was apparently alright and asymptomatic 12 days and then he experienced slip and fall on 15/4/24 and was taken to government hospital there he was diagnosed as intertrochanteric hip fracture and then shifted to ot there they have undergone surgery . On 17/4/24 patient developed altered sensorium and is so irritable and for further four days he is under observation of doctors and the concerned doctors did not inform the accurate cause to the patient attenders and then he was discharged  After discharge patient was at home with same irritable condition and altered sensorium for four days and again on 24/4/24 he suddenly developed SOB and then the patient attenders  admitted him to hospital there he had undergone CT brain suggested age related changes and for SOB they followed conservative treatment and altered sensorium is present And on Saturday at 2 Am patient loss consciousness so they s
Read more

65F Heart failure with preserved ejection fraction , ITP

Image
 A 65 years old female came to opd with c/o breathlessness since one week, insidious onset gradually progressive, grade 2-3 nyha, aggrevated on exertion, relieved with rest HOPI:  Patient was apparently asymptomatic 10 days back then developed shortness of breath. H/o generalized weakness and easy fatiguability  No h/o chest pain, palpitations, syncope, orthopnea, pnd No h/o cough, cold, fever, abdominal distension, facial puffiness, pedal edema, decreased urine output Past history:  h/o similar complaints in 2010, got 3prbc transfusions for Anemia, normal bone marrow biopsy, negative direct indirect coombs, in 2011 treated with steroids K/C/O: 2mnths back got dental procedure done, associated with blood loss, and started on steroids N/K/C/O : DM/ HTN /CAD / CVA / ASTHMA / THYROID /SEIZURE DISORDERS Personal history :  _ occupation : homemaker Patient is married  Patient takes mixed diet appetite is lost  Bowel and bladder movements are regular Micturition is normal  No known allergies
Read more

DIABETIC KETOACIDOSIS [RESOLVED] WITH DENOVO DIABETES MELLITUS SECONDARY TO ACUTE ON CHRONIC PANCREATITIS

 Case History and Clinical Findings C/O PAIN ABDOMEN SINCE 3 DAYS. PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN HE DEVELOPED PAIN ABDOMEN SINCE 3 DAYS INSIDIOUS IN ONSET, LEFT LUMBAR REGION, SPASTIC TYPE OF PAIN,NON RADIATING. A/W VOMITING 3 EPISODES PER DAY A/W LOSS OF APPETITE SINCE 3 DAYS H/O CONSTIPATION SINCE 3 DAYS,STEATORRHOEA H/O BLOATING NO H/O FEVER ,LOOSE STOOLS NO H/O BURNING MICTURITION NO H/O DECREASED URINE OUTPUT PAST HISTORY: H/O SIMILAR COMPLAINTS IN THE PAST N/K/C/O HTN,DM,CVA,CAD,EPILEPSY,ASTHMA NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA. VITALS: BP:130/80 TEMP:97 RR:31 COURSE IN HOSPITAL: THIS IS A CASE OF 36 YR OLD MALE CAME WITH C/O PAIN ABDOMEN SINCE 3 DAYS A/W VOMITINGS 3-4 EPISODES PER DAY.PATIENT WAS EVALUATED AND DIAGNIOSED WITH DIABETIC KETOACIDOSIS,ACUTE O CHRONIC PANCREATITIS PATIENT WAS ADVISED FOR CECT ABDOMEN I/V/O PANCREATITIS BUT PATIENT AND ATTENDR DENIED FOR IT. ANTIBIOTICS ADEQATE,REHYDRATION WITH FLUIDS,SUGAR CONTROL
Read more