20 year old male with fever since 6 days, generalised weakness and bodypains 4 days ago, black colored stools since 4 days

 M. Sri Nithya

Roll. No- 86

Unit-2

20 year old male B Pharmcy student presented to the OPD with the complains of fever since 6 days, generalized weakness and bodypains 4 days ago , black coloured stools since 4 days


HOPI

Patient was apparently asymptomatic 6 days ago then he developed fever High grade, associated with chills and rigors, more during nights, relieved with mediation.

Generalized weakness and body pains 4 days ago now subsided 

Black coloured stools since 4 days

No history of cough, cold , shortness of breath, vomiting, loose stools , bleeding from mouth, pain abdomen.


Not a known case of HTN DM CAD thyroid or seizure disorder

Family H/o - not significant


On general physical examination -

PATIENT is conscious, coherent, cooperative

There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema

Family history - not significant

On general examination -

PATIENT is conscious, coherent, cooperative

Well orientated to time, place and person

Vitals

PR:82/min

Supine Bp: 110/70 mmhg

Standing BP: 110/60 mmhg

Temp:97.2f

SPO2:98 ON RA

RR: 16/MIN

CVS:S1,s2 

Rs : BAE, NVBS

P/A - soft, non tender


Investigations -

Hb- 13.9

TLC-3700

PC-26000


RBS-126 MG/DL

B. UREA-16mg/dl


LFT-

TB-0. 94

SGOT-102

SGPT-71

T PROTEINS- 5.6

A/G-2 . 15

S CALCIUM-9. 9

S CREAT-0. 8

Na-139

K-4. 3

Cl-104

Ca2+- 1.15

Uric acid-4. 5


DIAGNOSIS: DENGUE FEVER WITH THROMBOCYTOPENIA


TREATMENT: IVF NS 100 ML/HR

TAB DOLO 650 MG PO/TID

INJ NEOMOL 1 GM IV/SOS ID TEMP MORE THAN 101F


USG ABDOMEN-



CHEST XRAY-



ECG-


Stool for occult blood- negative


17/02/23

AMC-BED NO. 1

UNIT-2

DOA- 16/2/23


20 year old male student came with the complaints of fever since 6 days, generalised weakness and body pains since 4 days, black colored stools since 4 days

S-

No fever spikes yesterday

Stools passed

Feeling better


O-

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE,

AFEBRILE ON TOUCH

BP - supine position-120/80mmHg

Standing position - 100/60 mm Hg

PR - 84/min

Temp - 96.2F

RR - 18/min 

Spo2 - 98% @RA

Grbs-93mg/dl

Input-3500

Out put-900

CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - NAD


Investigations -

Hb- 14.2g/dl

TLC- 4000

PLC- 58000


S electrolytes-

Na-138

K-4.4

Cl-105

Ca2+ 1.10


A-

Dengue fever with thrombocytopenia 


P

IVF-NS , RL @100 ML/HR

INJ. NEOMOL 1GM IV /SOS

TAB DOLO 650MG PO/BD

STRICT INPUT OUTPUT CHARTING

MONITOR VITALS AND INFORM SOS


 18/02/23

AMC-BED NO. 1

UNIT-2

DOA- 16/2/23


20  year old male student came with the complaints of fever since 6 days, generalised weakness and body pains since 4 days, black colored stools since 4 days

S-

No fever spikes yesterday

Stools passed yesterday night

No bleeding manifestations


O-


PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE,

AFEBRILE ON TOUCH

BP - supine position-120/70mmHg

Standing position - 120/80 mm Hg

PR - 80/min

Temp - 97.4F

RR - 16/min 

Spo2 - 98% @RA

Grbs-101mg/dl

Input-4200

Out put-1250

CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - NAD


Investigations -

Hb- 14.1g/dl

TLC- 3900

PLC- 1.10

Neutrophils -18

Lymphocytes -73

Pcv- 41. 8


A-

Dengue fever with thrombocytopenia 


P

IVF-NS , RL @100 ML/HR

INJ. NEOMOL 1GM IV /SOS if temp>101F 

TAB DOLO 650MG PO/BD

STRICT INPUT OUTPUT CHARTING

MONITOR VITALS AND INFORM SOS






Comments

Post a Comment

Popular posts from this blog

70yr old male with altered sensorium secondary to ?Meningitis

Image
  Sri Nithya Roll.no-86 ICU-BED. NO -03 A 70 Years Old Man Who was a Farmer By Occupation Presented to Casualty With  Altered Sensorium Since 3 Days  Fever Since 20 Days  HOPI :  Patient Was Apparently Asymptomatic Till 2014 ; 2014 - Patient Had Fever Associated with Cough for which he went to Hospital & Was Diagnosed to Have ? Pneumonia with DENOVO DM2 & Was Prescribed with OHAs ( Tab.METFORMIN & Tab.GLIMIPRIDE ) 6 Months Back - Patient Had Fever Associated with Cough for Which he Went to Hospital & Said to Have High Sugars along with Lung Infection ; Got Treated & Discharged in a Hemodynamically Stable Manner.Started using insulin for Diabetes Since Then  20 Days Back : Patient Had Fever with Cough ; For Which He went to Hospital & Suspected to Have TB But Reports Turned out to be Negative & Patient Discharged as LAMA & When He Returned Home 3 Days Back He Gradually Developed Altered Sensorium & Couldn't Recognise His ...
Read more

70 year old male came with the chief complaints of chest pain ,cough,sob

Image
 70 year old male came with the chief complaints of chest pain ,cough,sob since 8-10 days Fever since 1 week Hopi- Patient was apparently asymptomatic 8 days back then he developed cough- Dey,insidious in onset and gradually progressive,diurnal variations present more during night. No seasonal variations. No aggravating or relieving factors. Chest pain left sided non radiating not associated with excessive sweating, palpitations,pedal edema,giddiness Sob since 8 days insidious in onset and gradually progressive,progressed from grade 1 to grade 3 . No orthopnea,no PND No seasonal variation,no diurnal variation. Fever since 1 week ,high grade associated with chills and rigors, Evening rise of temperature present, loss of weight present, loss of appetite present No h/o vomiting,losing stools,pain abdomen. Past h/o-  K/c/o HTN since 2 years K/c/o DM since 6 months Not a k/c/oNot a k/c/o asthma , tb , epilepsy and thyroid disorders  Surgical history - ?patient underwent explor...
Read more

INTERNAL ASSESSMENT

Image
  1) Cerebrovascular accident etiology, clinical features, complications and management.   2) Causes, clinical features, complications and management of chronic renal failure. 3) Diabetic keto acidosis clinical features and management. 4) Clinical features and management of congestive cardiac failure. 5) etiology, clinical features and complications of liver cirrhosis. 6) Oppurtunistic infections in AIDS 8) Clinical features, differential diagnosis and management of Guillian Barrie Syndrome. 7) Approach to acute diarrhoea. 9) Secondary causes of hypertension. 10) Mention clinical features of Hansen's disease  11) Babinski's sign. 12)  Gastroesophageal reflux disease. 13) Clinical features of Dengue fever. 14) Pulmonary edema 15) Causes of thrombocytopenia. 16) Causes of pleural effusion.
Read more