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Chief complaints:-
Vomiting since 4 days
Fever since 4 days not associated with chills
Loose stools since 3 days not associated with blood.
History of presenting illness:-
The patient started developing these symptoms 5 days ago. He was at home when he got up from his bed and started vomiting (projectile) with the vomit comprising food or water, depending on what he consumed. He came to the hospital on the same day (6.10.2022) with complaints of projectile vomiting. He had 4-5 such episodes in one day. Even after vomiting everything that he consumed (in an episode), he still retched afterwards 3-4 times with no vomit. He then passed watery, greenish stools 4 times that day which was associated with squeezing type of pain in the epigastric region and developed a high grade fever. He also had associated shortness of breath. He came to this hospital on the same day, was medicated for it and discharged the next day.
The symptoms, however, did not subside and the patient was rushed to the ICU at 4pm on 9.10.2022 with complaints of vomiting and not being able to consume anything without vomiting. He hasn't been passing any stools till 9:30am yesterday.
Daily routine:-
He usually gets up early in the morning at 5am.Then he does his daily activites.He will have his breakfast at 7-8am.Then if he has any works he will go out otherwise he will stay at home.He will come home by 6pm and fresh up and have dinner by 8pm.He usually eats rice or chapatti or jowar roti.he usually sleeps by 9pm.
Past history:-
Known case of
Hypertension since 8 yrs
Diabetis mellitus type 2 since 8 yrs
Asthma since 6 months
Not known case of
Tuberculosis,leprosy, Cardiovascular diseases,chornic kidney disease and any other chronic illness.
He has been having joint pains since 10 years and has been going to the hospital repeatedly for his pains. He took painkillers and continued to work everyday till 4 days ago.
From 3 years ago, the patient has been getting scaly, itchy rashes with peeling of skin on his arms and legs. He was told this was due to diabetes.
Surgical history:- not significant
Drug history:-
For diabetes-
Tab.BAMILODIPINE 5mg+ATEMOLOL 50mg
For Hypertension -
Tab.METFORMIN 500mg
For asthma-?
Personal history:-
Diet-mixed
Built-well built (obese)
Appetite -decreased
Bladder movment-normal
Bowel movements- irregular
Allergy-generalised itching
Addiction-alcoholic 38 yrs ago,chew betel leaf and Tobacco regularly but stopped 5 days ago.
Family history:- not significant
General examination:-
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema present
Vitals:-
Temperature: 98.6°F
Blood pressure: 100/60 at time of admission
Pulse rate: 84bpm
Respiratory rate: 20/min
Spo2: 98%
GRBS: 121mg%
The swelling on the dorsum of his left hand is 4×5 cm in size, elliptical, firm, non-reducible. Slip test is positive.
Systemic examination:-
Cvs- thrills-no
Cardiac sounds -s1,S2 heard
Cardiac murmur- absent
Respiratory system: position of trachea is central, vesicular breath sounds heard.
Abdomen: abdomen is distended and umbilicus is central, everted. Tenderness in the right hypochondrial and epigastric regions. Liver is palpable.
CNS: Patient is conscious, coherent and cooperative
Glasgow coma scale: 15/15 f4v5m6
Investigations:-
2D echo:
ECG:
Provisional Diagnosis:-
Acute gastroentritis
Treatment:-
10/10/22-
11/10/22
12/10/22
