General medicine case
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A 55 year old male farmer by occupation came to the casuality with chief complaint of loose stools since 5 days 6 to 8 episodes per day which is water in consistency .
History of Present illness:
- Patient had suffered from one day fever which is intermittent in onset and subsided after taking medication.
- Initially patient also suffered from pain in abdomen on consuming food which is colicky type , intermittent , not radiating later on from past 2 days patient experiencing blood while passing stools 1 to 2 episodes per day along with watery stools .
- history of weight loss is present
- History of outside food consumption 5 days back .
- No history of vomitings , cough , cold , shortness of breath .
- No history of burning micturtion , hemoptysis.
Past history :
- No history of Hypertension, diabetes mellitus.
- No similar history in the past
- No history of Asthma , Epilepsy , Tb
- No surgeries in the past
Personal history:
Diet - Mixed
Appetite- decreased
Sleep - Decreased
Occasionally Alcoholic
No smoking or tobacco chewing habits
Family History :
No history of similar case in family
No cancer deaths in the family
General examination:
- Patient is conscious, coherent , and cooperative.
- Moderately built and moderately nourished
- No pallor , icterus , clubbing , cynosis, edema.
Vitals :
Temperature: Afebrile
Pulse rate : 90bpm
BP : 140/ 190 mmhg
SpO2 : 99% at RA
CVS :
S1 S2 heard , No murmurs
RESPIRATORY SYSTEM :
Position of trachea- central
Bilateral decreased air entry +
PER ABDOMEN :
Abdomen is soft and mildtendernss + in hypogastrium
Bowel sounds heard
CNS :
Patient is conscious, oriented to time, place and person
Motor and sensory system: Normal
Cranial nerves : intact
Reflexes : Present
No meningeal signs
Provisional diagnosis :
Acute dysentery
Acute on chronic pancreatitis secondary to cholelithasis
Investigations:
PROCTOSCOPY FINDINGS :
Mucosa helathy
No signs of erosion
Internal hemoerhoids present at 3`o clock and 6`o clock postion
RYLES ASPIRATE :
SURGERY REFERAL
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