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I am Nomika. Alli (Roll no 179) of 8th Sem MBBS.
A 69 year old male Resident of Mellacheruvu (Suryapet) , shopkeeper by occupation came to the OPD on 24th August 2023 with complaints of 10-12 episodes of greyish black colored vomitings since one day.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic one days back and then developed mild epigastric pain and discomfort in the chest on the morning of 23rd August 2023. After lunch he developed 10-12 episodes of non projectile vomiting which is watery, containing food particles, greyish black (bilious ?) in color , non foul smelling, non blood tinged , continuing throughout that day and night and morning of 24th August 2023.
No H/O abdominal pain , loose stools, giddiness
Patient was irritable that night(23rd august 2023) and didn't sleep .
No H/O Fever, cough
His daily routine is waking up at 6: 00 am, drinks tea at 7:00 am, breakfast (idli/ dosa/ other South Indian breakfast) at 8:00 am and go to work. He used to have his lunch as rice and curry at 1: 00 pm and some tea with biscuit at 5 :00 pm .He usually haves his dinner as chapati/rice with curry/ other breakfast at 9:00pm and goes to bed by 10:00 pm.
The patient used to lead a normal life until one day before these episodes.
HISTORY OF PAST ILLNESS:
K/C/O DM type II since 20 years.
On Biphasic insulin: 100(before breakfast)------x------150(before dinner)
N/K/C/O: HTN/ TB/ asthma/ CAD/CVD/ Epilepsy
No similar complaints in the past
No previous reflux disorders
SURGICAL HISTORY: none
FAMILY HISTORY: Patient's father is known Diabetic.
N/K/C/O: HTN/ TB/ asthma/ CAD/CVD/ Epilepsy
PERSONAL HISTORY:
Married
Shop keeper by occupation
Diet: Vegetarian
Appetite: Normal
Sleep: adequate
Bowel and bladder movements: Regular
Addictions: none
Allergies: no known
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative to time, place, person.
Ht: 165cm wt: 75kg
Pallor: no
Icterus: no
Cyanosis: no
Clubbing: no
Lymphadenopathy: no
Edema: no
Malnutrition: no
Dehydration: no
Vitals: BP: 160/90 mmHg
PR: 102bpm
RR: 18 cpm
Temp: 98.4°F
SpO2: 98%
GRBS: 335mg%
SYSTEMIC EXAMINATION:
CVS: S1 S2 heard
no thrills
no murmurs
RS: no dyspnoea
no wheeze
central position of trachea
normal vesicular breath sounds +
ABDOMEN: Shape: scaphoid
no tenderness
normal hernial orifices
no free fluid
no bruits
liver and spleen not palpable
CNS: conscious
normal speech
no neck stiffness
kernig's sign negative
cranial nerves, motor system , sensory system: intact, normal
Glasgow scale: E4V5M6
Cerebellar signs- no
finger nose in coordination: yes
Knee heel in coordination: yes
GAIT: normal
MUSCULOSKELETAL SYSTEM: normal
PROVISIONAL DIAGNOSIS:
DIABETIC KETOSIS
with TYPE II DM
with ??DENOVO HTN
PHYSICAL EXAMINATION:
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