Case-1
Aug 9,2021
Date of Admission-31-7-21
A 60 year old female presented to OPD with chief complaints of diffuse abdominal pain since 7-10days
HISTORY OF PRESENT ILLNESS
Patient was diagnosed in the nearest hospital 1 year back due to bloating of stomach.
The Patient didn't undergo for the further treatment at that time.
Patient was suffering from abdominal pain since a month ago and went to the nearest hospital.
Test were performed and the reports shown that she is hypoglycemic, hyponatremic and CRP was extremely high about 92.7mh/l and serum creatinine level was 8.9mg/dl.
She was refered then to KIMS for further treatment.
She is undergoing dialysis(4) since then
She complains of hard stool and prescribed with liq paraffin and milk of magnesia syrup 10ml 3 times a day.
She was hypovolemic and undergone blood infusion of 1 unit ( Blood group- B+)
HISTORY OF PAST ILLNESS
No history of surgery, asthma, TB, CAD, epilepsy.
PERSONAL HISTORY
Decrease appetite
Bowel movement is irregular since 1 month
Menopause attained 10years back
No addictions
Sleep adequate
FAMILY HISTORY
No history of DM, CAD, Asthma and thyroid disorders in the family
GENRAL EXAMINATION
Patient is conscious, coherent, co-operative.
There is no signs of icterus, clubbing, pallor, cynosis, lymphadenopathy
VITALS
Temperature- afebrile
Pulse rate- 86 bpm
Respiratory rate - normal
BP- 90/70
Spo2- 100%
SYSTEMIC EXAMINATION:
Cardiovascular System
Thrills- No
Cardiac sounds- S1, S2
RESPIRATORY SYSTEM
Position of trachea- central
Breath sounds- vesicular
Adventitious sounds- No
ABDOMEN
Shape of abdomen- scaphoid
Mild tenderness
Palpable mass- No
Hernias orifices- No
Free fluid- No
Bruits- No
Liver- Not palpable
Spleen- Not palpable
Bowel sound- Yes
CENTRAL NERVOUS SYSTEM
Patient is conscious
Speech- normal
No sign of meningitis irritation
Motor and sensory system- Normal
Cranial nerves- intact
Investigation
RFT- 4/8/2021
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