54 M with fever ,vomiting ,SOB

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Ch.nagatarun

Date of admission of patient : 26/11/2023

Case:  54 years old male came to OPD with vomitings , fever , SOB  since 5 days

Chief complaints : 

Fever since 5 days 

SOB since 5 days 

Vomitings since 3 days 

History of present illness :

The patient was apparently asymptomatic 5 days back then he developed fever, high grade, not relieved with medication , associated with chills and rigors and not associated with burning micturition , significant loss of weight.

SOB since 5 days, grade III , no orthopnea , pnd.

Also presents with vomitings since 3 days, non bilious, non blood stained , watery, 2-3 episodes foul smelling seen per day .

Ulcer over left foot,since 4 months, associated with edema of foot which is seen upto the level of ankle .

He also developed blebs over the plantar aspect of the left leg which made him slightly difficult in walking .

Before developing of these symptoms he used to 

History of past illness:

Known case of diabetic 14 years 

Known case of hypertension 20 years 

Not a known case of TB , thyroid,asthma ,epilepsy,cad,cva.

Treatment history:

For diabetes :glimiperide 

For htn:amlodipine

Family history :

Postive family history of his father and mother with diabetes.

personal history :

Sleep: adequate

Diet : vegetarian

Appetite :decreased currently 

Bowel and bladder movements normal 

General examination :

Patient is concious, coherent and cooperative.

He is moderately built ,moderately nouriched currently .

Pallor : absent 

Icterus :absent 

Clubbing: absent 

Oedema : present on left leg ,upto ankle  grade 1

Cyanosis:present 

Genaralised lymphadenopathy: no 

Sarcopenia and central obesity seen 

Vitals --

Bp: 120/80

PR: 98bpm

Rr:26 cpm

Temp:febrile (103.1 f)

Fever charting:

Systemic examination:

Cvs: s1 and s2 heard 

Resp:

 Respiratory system

Inspection :

Chest moving equally bilaterally on respiration

No visible pulsation no engorged veins

No scars and sinuses

Palpitation : 

All inspectory finding are confirmed on palpation

Trachea central

Bilateral equal chest movements

Tactile vocal fremitus equal in both side lung fields

Percussion :

Resonant in all fields

Auscultation :

Clear in all fields

NVBS heard

Abdomen: soft and non tender

CNS examination:

Higher mental functions normal

Cranial nerves normal

Sensory system

Fine touch normal

Crude touch normal

Vibration sensation 

Motor system:

Tone normal 

Power 

Biceps 5/5

Triceps5/5

Quadriceps5/5

Gluteus maximus 5/5

Reflexes 

Biceps jerk ++

Triceps jerk++

Knee jerk ++

Ankle jerk ++

Cerebellar signs negative

Meningeal signs negative

Chest x-ray

Investigations:

At admission 

Grbs :311 mg / dl

On 28/11/23..

O/E 

    PR 92bpm

    BP  140/90

     RR 26cpm 

    GRBS  157mg/dl 

   

   RR - nvbs 

  FBS 

  PLBS - 178 mg/dl

On 28 nov 

Rft:

cbp:

On 29 nov:

CBP:

rft:

Provisional diagnosis:

Type 2 diabetes mellitus

With diabetic foot on left leg

With hypertension.