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
Rft:
On 29 nov:
CBP:
Provisional diagnosis:
Type 2 diabetes mellitus
With diabetic foot on left leg
With hypertension.
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