Case history 12

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A 80 year old male has come to OPD with chief complaints of constipation since 8 days and no urination since 8 days and stomach pain , alternating to left and right since 8 days after having food.

HISTORY OF PRESENT ILLNESS  :

Patient was apparently well 3 years back and then developed pain in the abdomen ( epigastric) after taking food.  Then before 6 months back he had medication from local hospital and the  pain got subsided

And had had severe pain 8 days back .

PATIENT DAILY ROUTINE BEFORE ILLNESS:

Patient , being a farmer before 3 years , used to wake up around 5-6 in the morning have breakfast and leave for work then return to home around 6 and have dinner at 8 to 9 in night and go back to sleep.

Patient has have a habit of smoking betal , continues .

PATIENT ROUTINE AFTER ILLNESS :

Patient has stopped working as farmer but he used to do the cattle work from 3 years. One day on while working with cattle he had pain in the stomach due  , for which he went to local hospital and was given medication. On medication he had reduced pain in the stomach. But sometimes he had pain after having food mainly the citrus fruits and vegetables. Sometimes he had constipation for which medication was given and had normal stools then. But he had severe pain 8 days back with no urination and constipation .

PAST MEDICAL HISTORY:

Patient has no history of diabetes, asthma, hypertension , tuberculosis.

Patient was not underwent any surgery before.

FAMILY HISTORY:

No revelent family history.

PERSONAL HISTORY:

Diet: mixed

Appitite: decreased. Constipation : since 8 days.

Bowel bladder movement: normal.

Addictions : patient has habit drinking alcohol  regularly and smoking regularly .

GENERAL PHYSICAL EXAMINATION:

Patient concern was taken and examined in well lit room.

No pallor, cyanosis, icterus , clubbing and lymphadenopathy. 

Patient has no pedal oedema, bleeding gums, rashes and haematasis.

VITAL SIGNS:

Temperature : aferible

Pulse rate : 94beats /minutes.

BP: 130/ 90 mmHg.

Respiratory rate:18/minutes.

SpO2:98%

SYSTEMIC EXAMINATIONS

Cardiovascular system:

No thrills and cardiac mummurs .

S1 and S2 are heard .

Respiratory system:

No wheezing and dyspnoea.

Positioning of trachea is central and breath sounds are vesicular.

Abdomen:

Abdominal distinction not seen.

No tenderness and no palpable mass is present.Hernial orfices are normal.

No free fluid and bruits and liver and spleen are not palpable .

bowel sounds are not heard .

Central nervous system:

Patient is conscious and speech is normal.No signs of meningeal irritation such as neck stiffness and kerning's sign.

Cerebral signs such as finger - nose in coordination and knee - heal incoordination are not present .

INVESTIGATIONS:

Ultrasound :

Color Doppler 2D echo:

Complete blood picture:

Serum creatinine:

Blood sugar- reduction:

Serum electrolytes:

HBsAg-rapid:

ECG:

PROVISIONAL DIAGNOSIS:

Constipation secondary to paralytic ileus .

TREATMENT:

IVF-NS 50ml/hr.

Inj. PAN 40MG IV/OD 

INJ. MEROPENEM 500MG/IV/OD

NEBULISATION +SALBUTAMOL

SYP.LACTULOSE 20ML PO/BD

TAB.ECOSPORIN GOLD 20MG/OD

PROCTOCYLYSIS ENEMA

BP/PR/TEMP CHARTING 4TH HRLY. 

INJ.LASIX 20MG/IV/BD 

STRICT I/O CHARTING