GENERAL MEDICINE

CASE SCENARIO 

Pt aged 75 yrs M farmer by occupation came to opd with c/o 5 days back(Tuesday) has loose stools(4 episodes) and fever for 2 days (tue and wed) then on Friday he went to a pvt hsptl with c/o of generalised weakness .

HISTORY OF PRESENT ILLNESS

Pt was apparently normal 6 yrs back and got diagnosed with pulmonary TB and took treatment for 1 yr and got controlled on TB.

Then he again started smoking and 3 yrs back he again again developed wheeze and on medication for TB               

3 months Back the wheeze is aggregated and and 5 days back he has 4 episodes of loose stools which were non mucous non blood stained  watery and small quantity and fever for 2 days and generalised weakness since 5 days and grade III dyspnea since a week

HISTORY OF PAST ILLNESS 

Pulmonary TB and on medication 

N/k/c/o DM,HTN

TREATMENT HISTORY

Pt is on TB medication .

PERSONAL HISTORY 

Mixed diet

Farmer by occupation

Decreased appetite 

General Examination

No pallor 

Icterus present 

No cyanosis

No clubbing 

No lymphandenopathy 

No oedema 

Vitals 

Temp - 99F°

BP - 100/70mmHg

Pulse - 82Bp

Resp rate - 26/min 

Spo2 - 92%

Systemic examination 

Cardiovascular system

No thrills 

Cardiac sounds S1 S2 heard 

 No Cardiac murmurs 

Respiratory system

Dyspnoea present

Wheeze present

Abdomen 

obese abdomen 

No tenderness 

No palpable mass 

No bowel sounds 

Central Nervous System

Conscious 

 Normal Speech

No neck stiffness 

No kerning's sign 

Investigations 

ECG 

HEMOGRAM 

SERUM ELECTROLYTES 


ABG

Provisional diagnosis

Acute gastroenteritis with old pulmonary koch's 






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