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.




Comments

Post a Comment

Popular posts from this blog

CVA case

  A 70 years old male farmer by occupation presented to the casualty with complaints of weakness of right upper and lower limb with  inability  to talk since yesterday (8/9/23) Date of Admission: 08/09/23 CHIEF COMPLAINTS   Weakness of right upper and lower limb since 5 days. Inability to talk since 5 days. HISTORY OF PRESENTING ILLNESS   Patient was apparently asymptomatic since 5 days back and then speech got slurred while having lunch.He developed marked weakness in right upper and lower limbs.   Next day weakness persists and he was not able to talk so they brought to the hospital.  Weakness was sudden in onset non progressive. No aggravating or relieving factor. Slurring of speech was sudden and progressed to inability to talk.  H/o Drooling of saliva  H/o hiccups  No h/o deviation of mouth  No h/o involuntary movements, bladder and bowel incontinence  No h/o loss of consciousness  No h/o breathlessness , cough, fever, palpitation, reduced urine output and vomiting.  HISTORY OF PA
Read more
Image
  AKI 2° to Rt nephrectomy  Case scenario:- PT aged 40 yrs F Farmer by occupation came to opd with c/o of Vomitings since 15 days nausea since 15 days Pt was apparently normal 4yrs back then she had burning micturition pedal edema and rt loin pain and diagnosed with renal calculi(2 to 3 cm) Pt has right kidney nephrectomy in 2018 HISTORY OF PRESENT  ILLNESS Since 10 to 15 days pt had nausea and Vomiting  HISTORY OF PAST ILLNESS Right kidney nephrectomy in 2018 N/k/c/o BP and HTN PERSONAL HISTORY  Mixed diet Married Farmer by occupation  PHYSICAL EXAMINATION  Patient is conscious, coherent and cooperative •Moderately built and Moderately nourished •No signs of - Pallor                        Cyanosis                        Clubbing                        Icterus VITALS • Temp - 98.4F •Pulse rate - 82 BPM •RP - 16 /min •BP - 130/70 mm hg •SPO2 - 98 SYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM • S1, S2 heard • No murmurs RESPIRATORY SYSTEM:   •Position of trachea - central •Breath sounds -
Read more