General medicine case 1

Aug 10,2021

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Date of admission:07/08/2021

A 45 year old female presented to the OPD with chief complaints of fever, vomiting,diarrhoea. 

History of present illness:

Patient was apparently asymptomatic 6 months back before standing illness, then 2 days back patient was presented to casualty with with intermittent fever, vomiting 20 episodes, diarrhoea 20 episodes.

There is a sudden loss of weight since 2 months. 

It all started 6 months back where the patient had the complaints of fever and has taken the treatment from a local doctor and was fine for nearly 2 months.

After 2 months, fever has recurred and this time the patient even complains of weight loss. The normal treatment was done.

Then, patient was normal for 15 days.

After that patient was admitted in some hospital with fever, vomiting, diarrhoea on 26/7/21.Normal treatment was taken and was apparently better until 31/7/21 as given by patient.

On 07/08/2021 was admitted to kamineni due to recurrent fever and 20 episodes of vomiting and 20 episodes of diarrhoea.

Initially basic treatment was taken for dehydration i.e iv fluids and antibiotics were given.

No history of seizures, sudden loss of vision, chest discomfort, pain or SOB, loss of consciousness.

But there is weakness in general. 

Past history:

No history of DM/HTN/Epilepsy/TB/Thyroid disorders

Patient has undergone hysterectomy 16 years back due to which she had lost lot of blood. So the patient had undergone blood transfusion.

 Personal history:

There is loss of appetite. 

Diet:mixed

Bladder and Bowel movements:normal 

No addictions 

Family history:

No history of DM/HTN/CVA/CAD/Asthma/thyroid disorders. 

No history of similar complaint in family. 

Treatment history :

Not significant. 

General examination:

Patient is conscious, coherent and cooperative. 

Pallor is present.

No icterus,no cyanosis,no clubbing,no lymphadenopathy. 

Vitals:

PR-84 bpm

BP-130/80 mm Hg

RR-16 cpm

GRBS-110 mg/dl

Temperature-febrile

SpO2-98%

Systemic examination:

CARDIOVASCULAR SYSTEM:

Inspection:

Chest wall is bilaterally symmetrical.

No precordial bulge

No visible pulsations, engorged veins, scars, sinuses

Palpation:

JVP: normal

Auscutation:

Normal with regular heartbeat

S1, S2 heard

No murmurs 

RESPIRATORY SYSTEM-

Position of trachea: central

Normal Bilateral air entry 

No AV sounds

PER ABDOMEN:

Normal. No mass is palpable. 

No organomegaly

CENTRAL NERVOUS SYSTEM:

Patient is Conscious 

Speech: normal

Reflexes: present

Investigations :

Oral manifestation:

On 07/08/2021

Hemogram:

Liver function tests:

ECG:

Blood sugar :

Renal function test 

Provisional diagnosis:

Acute gastroenteritis? 

Final diagnosis:

HIV positive 

Treatment:

On 07/08/2021

INJ. METROGYL 100ml/IV/TID

INJ. CIPROFLOXACIN 500mg /IV /BD

INJ. ZOFER 4 mg/IV/OD

TAB. SPOROLAC DS/PO/TID

INJ. PAN 40mg/IV/OD

On 08/08/2021

INJ. METROGYL 100ml/IV/TID

INJ. CIPROFLOXACIN 500mg/IV/BD

INJ. ZOFER 4mg/IV/OD

TAB. SPOROLAC DS/PO/TID

INJ. PAN 40mg/IV/OD