42 Male with Acute GE

May 17, 2020

Hello. This is P.Ravi teja. 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

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

Hemogram: