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GENERAL MEDICINE


Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.


         CASE REPORT 

A 64 year old male with chief complaints of fever since 4 days, loose stools since 4 days , swelling of the left lower limb since a month and abdominal distension since one month . 

CHEIF COMPLAINTS: 
  • Fever since 4 days.  High grade a/w chills, decreases on medication.  
  • Loose stools since 4 days a/w mucoid, small volume, watery consistency 
  • Swelling of the left lower Limb since past one month 
  • Abdominal distension since past one month  
  • No h/o pain abdomen 
  • No h/o blood and pus in stools.  

HISTORY OF PRESENT ILLNESS: 
Nothing significant 


HISTORY OF PAST ILLNES 
bronchial asthma 
De novo  detected DM ?


TREATMENT HISTORY: 
Is on Asthma medication. 


PERSONAL HISTORY: 
Married. 
Appetite - normal 
Non vegetarian 
Bowels- regular. 
Micturition- abnormal 
Known allergies - none 


FAMILY HISTORY : 
Nothing significant.  


PHYSICAL EXAMINATION: 

GENERAL : 
No signs of pallor, icterus, clubbing of fingers or toes, lymphadenopathy or malnutrition.  
Dehydration - yes 
Oedema of feet - yes 

VITALS: 
  • Temp- a febrile 
  • Pulse rate - 90/min 
  • Respiration rate-26/min 
  • Bp- 80[systolic]/60  
  • Spo2: 98% at 4L of o2 

SYSTEMIC EXAMINATION: 
CVS: S1S2 ++ 

RESPIRATORY SYSTEM: 
  • Dyspnoea - yes 
  • Position of trachea - central 
  • Breath sounds - vesicular 

ABDOMEN : 
  • Shape of abdomen - scaphoid 
  • Tenderness - not 
  • Palpable mass- no 
  • Hernial orifices - normal 
  • Free fluid - no 
  • Bruits- no 
  • Liver- not palpable 
  • Spleen - not palpable. 
  • Bowel sounds - yes. 

CNS: 
Level of consciousness- conscious 
Speech- normal 
Signs of meningeal irritation- none 



INVESTIGATIONS: 

1.anti HCV antibodies - RAPID 



2. ABG 



3. HIV 1/2 rapid test :



4. SARS COV -2 PCR 



5. ECG


6. ULTRASOUND REPORT: 



7. HBsAg-RAPID 



PROVISIONAL DIAGNOSIS: 
Acute gastroenteritis 
With k/c/o bronchial Asthma 
With de novo detected diabetes 
With left lower limb cellulitis 
?septic shock 

TREATMENT: 

DAY 1: 

  • IVF- NS and RL = 1000ml/hr 
  • Inj. Hydrocort 100mg iv
  • CPAP ventilation 
  • Neb with budecort , 4th hourly 
  • Inj. HAI s/c acc to GRBS 
  • Tab sporlac DS po/TID 
  • Strict I/o monitoring 
  • Inj piptaz 4.5 gn IV/ stat 
  • Inj clindamycin 600mg IV/BD
DAY 2 : 

  • Inj streptokinase, 3 ml/hr 
  • Fluid restriction <1.5 l/ day 
  • Salt restriction <4gm/day 
  • Inj piptaz 2.25 gm /IV/ TID 
  • Inj clindamycin 600mg /IV/TID 
  • Inj. Hydrocortisone 100mg/IV/TID 
  • Inj. Neb with budecort 6th hourly 
  • Intermittent CPAP ventilation 
  • Strict I/o monitoring 
  • BP, PR, SPO2 monitoring hourly 
  • Inj. Heparin 1ml (1000IU) in 4 ml NS/IV/QID

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