GENERAL MEDICINE CASE PRESENTATION A 70 yr old male agriculture by occupation was brought to causality in an unconscious state since yesterday. CHIEF COMPLAINT: Fever since 3 days Abdominal pain since 3 days HISTORY OF PRESENT ILLNESS: * Patient was apparently asymptomatic 1 week back after which he started Binge drinking for 2 days. *He developed Fever that last for 3 days and developed Abdominal pain Burning type both for which he was treated by local Doctor. * After that he developed weakness which is gradual in onset and was unable to stand for which he was admitted to local hospital where he was diagnosed to have DENGUE FEVER (through NS1 ANTIGEN Positive) and the Platelet Count was 24,000. PAST HISTORY: *Patient is a known case of Chronic Alcoholism since 30 years and increased his intensity since last 3 years. *smoking since 20 yrs, average 2 beedi per day TREATMENT HISTORY: * No Past history of treatment PERSONAL HISTORY: * He is a chronic alcoholic since 30 years *
Popular posts from this blog
CVA case
A 70 years old male farmer by occupation presented to the casualty with complaints of weakness of right upper and lower limb with inability to talk since yesterday (8/9/23) Date of Admission: 08/09/23 CHIEF COMPLAINTS Weakness of right upper and lower limb since 5 days. Inability to talk since 5 days. HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic since 5 days back and then speech got slurred while having lunch.He developed marked weakness in right upper and lower limbs. Next day weakness persists and he was not able to talk so they brought to the hospital. Weakness was sudden in onset non progressive. No aggravating or relieving factor. Slurring of speech was sudden and progressed to inability to talk. H/o Drooling of saliva H/o hiccups No h/o deviation of mouth No h/o involuntary movements, bladder and bowel incontinence No h/o loss of consciousness No h/o breathlessness , cough, fever, palpitation, reduced urine output and vomiting. HISTORY OF PA
AKI 2° to Rt nephrectomy Case scenario:- PT aged 40 yrs F Farmer by occupation came to opd with c/o of Vomitings since 15 days nausea since 15 days Pt was apparently normal 4yrs back then she had burning micturition pedal edema and rt loin pain and diagnosed with renal calculi(2 to 3 cm) Pt has right kidney nephrectomy in 2018 HISTORY OF PRESENT ILLNESS Since 10 to 15 days pt had nausea and Vomiting HISTORY OF PAST ILLNESS Right kidney nephrectomy in 2018 N/k/c/o BP and HTN PERSONAL HISTORY Mixed diet Married Farmer by occupation PHYSICAL EXAMINATION Patient is conscious, coherent and cooperative •Moderately built and Moderately nourished •No signs of - Pallor Cyanosis Clubbing Icterus VITALS • Temp - 98.4F •Pulse rate - 82 BPM •RP - 16 /min •BP - 130/70 mm hg •SPO2 - 98 SYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM • S1, S2 heard • No murmurs RESPIRATORY SYSTEM: •Position of trachea - central •Breath sounds -
Comments
Post a Comment