Casehistory 53 yr old male pt (long case)
January 20.2023
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A 53 year old male patient who is daily wage worker by occupation came to opd whith chief complaints of fever , abdominal pain , fever , no passage of stools since four days
Hopi:
Pt was apparently asymptomatic four days back then he developed fever with chills , rigor, headache and constipation , pedal edema facial puffiness sob
Loss of appetite since 4 days
History of past illness: : K /c / o dm 2 since 10 years on regular medication metformin 500 mg
Appendicectomy done 2014
Spinal surgery done in 2016
N / k /c / o : htn ,thyroid ,tb ,asthma, epilepsy ,
Known alcoholic since 20 yrs regular stoped smoking fours yrs back , 2 packs of smoking daily before four yrs for 25 yrs
Personal history :
Diet : mixed
Appetite: loss
Sleep : adequate
BnB : irregular since 4 dys
Addiction: alcoholic
Family history : no such complaints in family
No history of drug allergy
General examination : pt was consious coherent cooperative and well oriented to time and place
No pallor , icterus , cyanosis , clubbing , lymphadenopathy
Moderately nourished
Spo2 : 92
Shape: scaphoid
Flanks:free
Umbilicus: central &inverted
no scars,no scratches,
No dilated veins
Movements are normal
No visible pulsations
Cullens sign - negative
PALPATION:
no raise of temperature
no tenderness
Kidney and spleen not palpable
no palpable mass
PERCUSSION:
No fluid thrill
No Shifting dullness seen
AUSCULTATION:
bowel sounds heard
No bruit
RESPIRATORY:
INSPECTION:
Chest: symmetrical
Trachea: central
No drooping of shoulders,
no kyphoscoliosis
no use of accessory respiratory muscles
Movement with respiration is symmetrical on both sides
PALPATION:
trachea: central
no intercoastal widening
Whole thorax measurement:34 inches
Hemi Thorax:17 inches
Vocal fremitus -normal
PERCUSSION:
Dullness noted from 5th intercoastal space
AUSCULTATION:
vesicular breath sounds
No added bruits
CVS:
S1&S2 heard
No thrills,no murmurs
Investigation:
