General medicine case-08
A 70 year old male patient,wage worker by occupation presented to the opd with the chief complaint of loose stools & vomitings.
History of present illness:
Patient was apparently asymptomatic 2 years back then he had decreased urine output following which he was diagnosed renal failure & prescribed medication.
Now,Patient complains of 3 episode of loose motions,watery in consistency,not associated with blood & 3 episodes of vomitings,non projectile,food particles as contents.
As he had fever,he went to the local hospital 4 days back,Grbs was done which was 500 mg/dl & referred to kims.H/o fever.
History of past illness:
The patient was known case of kidney disease.He also had decreased urine output for which he takes medication occasionally.
Not a known case of hypertension,diabetes mellitus,bronchial asthma,epilepsy & tuberculosis.No history of any surgeries.
Personal history:
Mixed diet
Bowel & bladder - Normal
Sleep adequate
H/o smoking,alcohol consumption
Loss of appetite
Family history:
No family history
General Examination:
The patient is conscious,coherent and cooperative.He is well oriented to time,place and person.
No Pallor
No Icterus
No Cyanosis
No Lymphadenopathy
No Pedal Edema
Temperature-100 degree F
Pulse rate-94 beats/min
Respiratory Rate- 17/min
Blood pressure- 80/60
SpO2 - 96% at room temperature
Systemic examination:
CVS : No thrills
S1 S2 +
RS- No dyspneoa,No wheeze
Breath sounds-Vesicular
per abdomen- soft,non tender
CNS- Conscious,Speech normal.
Provisional Diagnosis:
Acute Gastroenteritis secondary to viral infection.
Investigations :
Anti HCV Antibodies -RAPID:Negative
HBsAg-RAPID: Negative
HIV 1/2 Rapid Test:Non Reactive
Troponin-1:Negative
Complete Urine Examination:
Liver Function Test:
Complete Blood Picture:
Renal Function Tests :
Ultrasound Report -
Treatment-
1/12/2021
Inj Zofer 4mg IV
Inj Optneuron Cap IV
Tab Sporolac DS
Tab Dolo 650 mg
Inj Metrogyl 500mg IV
Inj Ciprofloxacin 500mg IV
2/12/2021
Inj Pantop 40mg IV
Inj Zofer 4mg IV
Inj Optneuron Cap IV
Tab Sporolac DS
Tab Dolo 650 mg
Inj Metrogyl 500mg IV
Inj Ciprofloxacin 500mg IV
Tab RC Dotil
3/12/2021
Inj Pantop 40mg IV
Inj Zofer 4mg IV
Inj Optneuron Cap IV
Tab Sporolac DS
Tab Dolo 650 mg
Inj Metrogyl 500mg IV
Inj Ciprofloxacin 500mg IV
