40 year old male patient with type II diabetes mellitus with diabetic foot, hypertension and acute gastritis.

2/12/2023

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Sanidha Singh 

Roll no.- 98

Unit 4

CASE

A 40 year old male patient came to the causality with complaints of vomiting since 6 PM on 30/11/2023.

HOPI : Patient was apparently asymptomatic 4 hours back on 30/11/23. He had his lunch ( egg curry and roti) at a Dhaba at 1 PM and then he developed vomitings - 8 episodes, non projectile, non- bilious, food particles as content.

C/o palpitation, sweating, SOB grade II MMRC.

No h/o chest pain, pain abdomen, headache.

No h/o giddiness, orthopnea, PND.

PAST HISTORY:

K/C/O DM since 2 years using Inj Mixtard ( 20U BBF and 10U BD)

K/C/O HTN since 2 months on Tab Telma H

N/K/C/O epilepsy, thyroid disorder, Asthma, CVA, CAD.

PERSONAL HISTORY:

Diet:Mixed 

Appetite: normal 

Sleep: inadequate

Bowel,bladder:regular movements.

Addictions: Occasional Alcoholic since 10-15 years and stopped only 2 months ago 

FAMILY HISTORY :No significant family history.

Not allergic to any drugs. 

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent,cooperative,well oriented to time,place,person.She is moderately built and nourished.

No signs of pallor, icterus, cyanosis, clubbing, lymphoedenopthy, oedema. 

Vitals:PR- 90 bpm

RR- 34 cpm

BP-140/90mm hg

GRBS- 139 mg % 

Temp- 98 F

SYSTEMIC EXAMINATION:

PER ABDOMEN:Soft,non tender and organomegaly 

CNS:No focal neurological deficits.

RESPIRATORY SYSTEM: BAE + , NVBS + , No added sounds 

CVS: S1 S2 + , No murmurs.

Investigations:                                                30/11/23:

                                                                          1/12/23:  

                                                                      2/12/23:

GRBS monitoring:         1/12/23

                                     2/12/23

Treatment: 

IV FLUIDS NS @ 100ML/HR 

INJ PIPTAZ 4.5 GM IV 8TH HRLY

INJ METROGYL 500 MG IV TID 

TAB LINEZOLID 600 MG 

INJ EMECET 8 MG IV BD

INJ PANTOLID 40 MG 

TAB TELMA H (40/12.5)

TAB DOMSTAT 10 MG TID

INJ PERINOM 10MG IV SOS 

OINTMENT MEGAHEAL FOR L/A 

PROTEIN POWDER 2 TBSP IN 1 GLASS MILK