General medicine case history-1

 Case history-1 

This is an online elog book to discuss our patient de-identified health data shared after taking his/her /guardians signed informed consent.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evident based input.

A 55 year old male pt, by occupation, r/o velimandu nalgonda came to the casualty with clo Sudden onset SOB ( Today 9:00PM) with Sweating 

pain and swelling of It Leg (since 3 days) 

pt had Binge of alcohal intake 2 days back then he

had 1 Episode of Vomiting> Non projectile, Non Bilious, contain food particles, Non foul smelling, From then pt is heavily decreased food intake,  pain & swelling of the left leg till knee, Not associated with any trauma

pt is having Soß (grade I-0) (since 1 year).

no orthopnea, PND .

 B/l Lower limb Edema (On and off) Relieves on taking medication.


HISTORY OF PAST ILLNESS: no h/o DM,HTN,Epilepsy,TB,,Asthma, fever ,loose stools,pain abdomen.

h/o similar complaints in the past.

H/O Smoking and alcohol since 30 yrs.

Chronic smoker -18 beedis/day.

chronic alcoholic 90ml/ day.


O/E

pt is conscious, coherent, cooperative

afebrile, BP,PR - not recordable.

 SPO2 -65%,GRBS 99 Mg/dl, RR- 15CPM,

P/A: SOFT, NON TENDER, BOWEL SOUNDS PRESENT.

SYSTEMIC EXAMINATION-

CVS- S1, S2 heard, no murmurs, no added sounds.

RS- BAE+,NVBS heard, trachea central in position.

P/A- soft, non-tender, no palpable mass or swelling.

CNS- NAD.


L/E: Edema present on lt lower limb, extending upto calf from toes.

loss of hair present, pain present on dorsiflexion of left foot, nails- brittle, skin over limb- shiny.

peripheral pulses - not recordable, not felt.

tenderness present on active as well as passive movements.

calf tenderness present .

no local rise of temp.

signs of vascular compromise +


SYSTEMIC EXAMINATION-

CVS- S1, S2 heard, no murmurs, no added sounds.

RS- BAE+,NVBS heard, trachea central in position.

P/A- soft, non-tender, no palpable mass or swelling.

CNS- NAD.


PROVISIONAL DIAGNOSIS-

HYPOVOLEMIC SHOCK 







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