A CASE OF 55 YR OLD MALE WITH SHORTNESS OF BREATH , VOMITINGS

November 01, 2022

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Date of admission: 31/10/2022

A 55 year old male, farmer by occupation came to casuality with shortness of breath, pain in lower abdomen

Chief complaint: Shortness of breath, pain in abdomen on touch since yesterday

History of presenting illness:

Patient was shifted to this hospital due to development of shortness of breath while getting discharged from another hospital in his locality where the patient was diagnosed with jaundice.

Patient was apparently asymptomatic 1 days back when he developed high grade fever since 1 week , vomiting since 3 days with 7 to 8 episodes of vomiting which was bilious, non projectile in character constituting of no food content for which the patient was taken to a near by hospital where he was diagnosed with Jaundice.

After discharging, the patient developed shortness of breath and was hypotensive in nature hence his attenders preferred to shift him to this hospital due to previous history of treatment here.

The patient also complained of diffuse abdominal pain on touch which was sudden in onset.

The patient was brought to the casuality around 9:00 pm.

History of past illness:

▪︎Patient is a known case of chronic kidney disease since 10 years

▪︎Patient is a known case of diabetes and hypertension since 5 years for which he is on medication since then

▪︎Patient was diagnosed with pulmonary TB in 2018 and was started on ATT for 6 months after which the patient recovered.

▪︎Not a known case of Asthma/ CVD/ Epilepsy/ Thyroid disorder

Personal history:

▪︎Diet: mixed type

▪︎Appetite: decreased since 1 week

▪︎Sleep: adequate

▪︎Bowel and bladder movements: Normal

▪︎Addictions : -

Surgery history:

▪︎Patient had undergone cataract surgery in right eye 10 years ago

▪︎Patient had undergone 3 surgeries due to cellulitis developed in his left lower leg as a result of diabetes between 2019 - 2021 when patient presented with similar complaints of bilious vomiting, loose stools with greenish discolouration and swelling in left lower leg

back then to this hospital

Drug history:

Patient was consuming pain killer (steroid composition) for joint pain which was purchased over the counter for last 10 to12 years. Patient was asked to stop its consumption 1month back.

Family history:

▪︎His father and mother were known case of diabetes and hypertension.

▪︎His younger brother is known case of diabetes

General examination:

On Examination, the patient is conscious, coherent and cooperative

▪︎Moderate built and nourishment

▪︎Icterus and non pitting type of pedal edema present