General medicine case-5
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
CHIEF COMPLAINTS:-
A 32years old male, construction worker by the occupation presented to the opd with the
C/O fever since 4-5 days
cough since 1 week
cold since 1 week
Headache and giddiness since 1 week
HISTORY OF PRESENT ILLNESS:-
Patient was apparently asymptomatic 1 week ago. Then he gradually developed Weakness ,low grade intermittent fever with no diurnal variation associated with non productive cough and cold.
Patients daily routine is, he wakes up at early in the morning 5:30. He goes to his work at morning 9'o clock then he takes his lunch at 2pm and go back to the home at 5:30 pm, he takes dinner at 8'o clock and sleep by 10'o clock.
PAST HISTORY:-
There is no history of hypertension, diabetes mellitus , tuberculosis, asthma, and epilepsy
There is no history of any surgery.
PERSONAL HISTORY:-
Married
Patient takes mixed diet.
Sleep-adequate
Appetite- normal
Bowel and bladder moments are regular.
Consumes alocohol once in 10 days - 90ml since 5yrs.
No h/o smoking.
FAMILY HISTORY:-
There is no history of similar complaints in the family members
GENERAL EXAMINATION:-
The patient is conscious, coherant and uncooperative. He is well oriented to time , place and person . Moderately built and nourished
No anemia
No Pallor
No icterus
No cyanosis
No clubbing
No generalized lymphadenopathy
VITALS:-
Temperature:98.6F
Bp: 110/70 mmHg
PR: 62bpm
RR:20
Spo2: 99% on room air.
SYSTEMIC EXAMINATION:-
CARDIOVASCULAR SYSTEM
Inspection:-
Chest wall is bilaterally symmetrical
No Precordial bulge
No visible pulsations, engorged veins,scars, sinuses
Palpation:
JVP - normal
In midclavicular line
Ausculation:
S1 ,S2 Heard
RESPIRATORY SYSTEM
Bilateral airway +
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
PER ABDOMEN
Abdomen is soft and non tender
Bowel sounds heard
Free fluid grade 1 ascites
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal
CLINICAL IMAGES:-
INVESTIGATIONS:-
CUE:-
USG Abdomen:-
On 26/10/2021
On 28/10/21
Platelet count:-1.30 lakhs
Day 1:-
26/10/21
Fever chart
Day 2
27/10/21
Day 3
28/10/21
DIAGNOSIS:-
Dengue fever with Thrombocytopenia
TREATMENT:-
IVF NS , RL @ 125 ml/hr
-INJ PANTOP 40 MG /IV/OD
-INJ ZOFER 4 MG /IV/SOS
-TAB DOLO 650 /PO/ SOS
-INJ NEOMOL 100 ML IV / IF TEMP > 101 F
-SYRUP GRILLINCTUS 10 ML PO/OD /TID WITH 1 GLASS OF WATER
-TEMP CHARTING 4 TH HRLY , TEPID SPONGING
-MONITER VITALS
-POSTURAL BP MONITERING 4 TH HRLY
-PLENTY OF ORAL FLUIDS .
Comments
Post a Comment