GENERAL MEDICINE CASE PRESENTATION 

 

A 70 yr old male agriculture by occupation was brought to causality in an unconscious state since yesterday.

CHIEF COMPLAINT: 

  • Fever since 3 days 
  • Abdominal pain since 3 days

HISTORY OF PRESENT ILLNESS:

* Patient was apparently asymptomatic 1 week back after which he started Binge drinking for 2 days.

*He developed Fever that last for 3 days and developed Abdominal pain Burning type both for which he was treated by local Doctor.

* After that he developed weakness which is gradual in onset and was unable to stand for which he was admitted to local hospital where he was diagnosed to have DENGUE FEVER (through NS1 ANTIGEN Positive) and the Platelet Count was 24,000. 

PAST HISTORY:


*Patient is a known case of Chronic Alcoholism since 30 years and increased his intensity since last 3 years. 

*smoking since 20 yrs, average 2  beedi per day

TREATMENT HISTORY:

* No Past history of treatment 

PERSONAL HISTORY:

* He is a chronic alcoholic since 30 years 

* He is smoker since 20 yrs at an average of 2 beedi per day

FAMILY HISTORY:

*No Familial History.

GENERAL EXAMINATION: 

* Patient was in an unconscious state.

*No icterus and pallor.

* No B/l pedal edema 

* No lymphadenopathy 

ON EXAMINATION:

BP: 90/60 mm Hg
PR: 102bpm
GRBS: 34mg/dl
Temperature: 99°F
RR: 36cpm
SpO2: 85% with 4 Liters of O2
Severe Thrombocytopenia with Bleeding Manifestations (Epistaxis)

INVESTIGATIONS:






CBP: 


CUE:

COLOUR: Pale Yellow
APPEARANCE: Clear
REACTION: Acidic
SP GRAVITY: 1.010
ALBUMIN: +
SUGAR: Nil
BILE SALTS: Nil 
BILE PIGMENTS: Nil
PUS CELLS: 4-6
EPITHELIAL CELLS: 2-4
RED BLOOD CELLS: Nil
CRYSTALS: Nil
CASTS: Nil
AMORPHOUS DEPOSITS: Absent
OTHERS: Nil

APTT :

APTT TEST: 32 sec

PROTHROMBIN TIME: 

PT : 16 sec

# INR: 1.1
# BLEEDING TIME: 2 min
# CLOTING TIME: 4 min 30 sec

BLOOD SUGAR RANDOM:


SEROLOGY: 

HIV 1/2 RAPID TEST:


HBsAg-RAPID:


ANTI HCV ANTIBODIES-RAPID:



LIVER FUNCTION TEST (LFT) :


RENAL FUNCTION TEST(RFT):


BLOOD GROUPING AND RH TYPE:


ABG:


CHEST RADIOGRAPHY:



PROVISIONAL DIAGNOSIS:

*Dengue shock syndrome
(??Dengue encephalitis) 
*With hepatitis SECONDARY to Dengue? Alcohol??
*With Pre renal AKI

TREATMENT:

1. 25% Dextrose for Hypoglycemia
2. IVF. NS Bolus 1 Litre.




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