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A 60 yr old female presented to opd with chief complaints of vomiting since 20 days fever since 2 - 3 days abdominal pain since 2- 3days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 20 days back then she had 4-5 episodes of vomiting which is non projectile and non bilious non blood tinged and had fever 2-3 days back and abdominal pain since 2 -3 days
Patient also gives history of joint pains she is unable to walk
HISTORY OF PAST ILLNESS
Patient gives the history of pedal edema went to local hospital 4 months back where she was worngly interpretted as Acute kidney injury.
Hypertension since 1 and half yr and on medication
No history of diabetes mellitus and asthma
PERSONAL HISTORY
Patient takes mixed diet
Loss of appetite
Sleep is adequate
Bowel and bladder movements are regular
No alcohol and smoking habits
GENERAL PHYSICAL EXAMINATION
Patient is conscious coherant and cooperative and well oriented to time place and person she well built
Pallor present
No icterus
No clubbing
No pedal edema
No generalized lymphadenopathy
VITALS
Temperature- afebrile
Blood pressure -110/70mmHg
Respiratory rate 12cycles
Pulse rate 72 bpm
Spo2- 98% room air
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Inspection:
Chest wall is bilaterally symmetrical
No Precordial bulge
No visible pulsations, engorged veins,scars, sinuses
Palpation:
JVP - normal
Apex beat : felt in the left 5th intercostal space
In midclavicular line
Ausculation:
S1 ,S2 Heard
RESPIRATORY SYSTEM
Bilateral airway +
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
PER ABDOMEN
Abdomen is soft and non tender
Bowel sounds heard
Swelling in the knee joint because of which she is unable to walk
Patient gave history of some blister formation that was due to infection which relieved on medication
INVESTIGATIONS
ECG
LFT
DIAGNOSISPeptic disease with severe duodenitis
TREATMENT
IV fluids 2 units NS 1 unit RL at 100 ml/hr
Inj pantop 500 ml
Inj zofer 4mg IV/ TID
Monitoring vitals
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