General medicine case discussion

20th Dec 2022

 CASE DISCUSSION 

A 55 year old male came to opd who was a labourer by occupation  came with

CHEIF COMPLAINTS:

Vomitings ( since 2days )

Pain in abdomen 

Breathlessness 

Decreased appetite( since 6days )


HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 6days ago and then he had decreased appetite and was consuming alcohol. vomitings started 2days ago along with breathlessness.

PAST HISTORY:

No cold

No vomiting 

No BP

No diabetes

No asthma

No TB

No Epilepsy

PERSONAL HISTORY:

Married

Mixed diet

Regular bowel movements

No allergies 

Normal micturation

Alcohol-Daily 180 ml since 20 yrs

Cigarettes- Daily 10 cigarettes since 15 yrs

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION:

No pallor

icterus is seen

No cyanosis

No lymphadenopathy 

No malnutrition 

No clubbing of fingers

Pedal oedema is seen





FEVER CHART:




HEMOGRAM:




ECG:




TREATMENT:

1. Inj Thiamine 1gm/IV

2. Inj PAN 40mg/IV/stat

3. Inj LASIX 40mg/IV

4. Inj Sodium bicarbonate 100Meq/IV/Stat

5. Iv Fluids

6. Inj Piptaz 4.5gm/IV

7. Tab DOLO 650mg





PROVISIONAL DIAGNOSIS: Sepsis with Multiple Organ Dysfunction

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