May 17, 2020
Hello. This is Raveena Reddy. I'm a medicine intern and I'm here to share my daily experiences here as a part of my internship completion.
Today's case :
A 45 year old male came to opd with chief complaints of decreased appetite since 1 month and loose stools since 20 days
HOPI
Patient was apparently asymptomatic 1 month back then developed decreased appetite , Increased chest discomfort immediately on taking food , gradually progressed
Loose stools since 20 days watery consistency, normal colour 4 episodes per day not blood stained patient. but, now complains of blood stained stools 1 episode per day normal consistency since 2 days after using medication
Patient complains of generalized weakness and not able to do daily activities
Belching present
No h/o fever, vomitings, pain abdomen,chestpain,cough ,sob.
Past history:
K/c/o HIV since 9 years
On regular medication TLE regimen
CD4+ count= 500cells/cu.mm on 4-07-2019
Pt is on INH from 1 month
No h/o Hypertension , diabetes, asthma , epilepsy
Not a k/c/o TB.
Personal history:
Sleep-adequate
diet-mixed
Appetite- decreased
Bowel and bladder - regular
Alcoholic since 10 years
Smoking since 10 years
Not allergic to any known drugs
Physical examination:
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No oedema
Vitals
Temperature- afebrile
Pulse - 82bpm
Respiratory rate - 12/min
BP - 120/70 mmHg
Grbs- 114mg/dl
Systemic examination:
CARDIOVASCULAR SYSTEM:
S1 s2 heard
no added murmurs.
RESPIRATORY SYSTEM:
Trachea central in position
Normal vesicular breath sounds heard
RESPIRATORY SYSTEM:
Trachea central in position
Normal vesicular breath sounds heard
b/l air entry present.
Abdomen:
Shape - scaphoid
No tenderness
No palpable liver and spleen
Central nervous system
Patient is conscious
Speech normal
Cranial nerves intact
Motor system normal
Sensory system normal
No signs of meningeal irritation
Investigations
Abdomen:
Shape - scaphoid
No tenderness
No palpable liver and spleen
Central nervous system
Patient is conscious
Speech normal
Cranial nerves intact
Motor system normal
Sensory system normal
No signs of meningeal irritation
Investigations
Hemogram:
ESR levels:
LFT:
serum electrolytes:
Stool for occult blood
Treatment :
Inj.ciprofloxacin 500mg/Iv/bd
Inj. Metrogyl 500 mg/iv/tid
T.bactrum ds 800/160 mg bd
TLE regimen
ORS
Iv fluids
ESR levels:
LFT:
serum electrolytes:
USG:
X-RAY:
RFT:
Stool for occult blood
Treatment :
Inj.ciprofloxacin 500mg/Iv/bd
Inj. Metrogyl 500 mg/iv/tid
T.bactrum ds 800/160 mg bd
TLE regimen
ORS
Iv fluids
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