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.

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