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.

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