CASE -1

Name: A. Greeshma 
Roll no : 148
Introduction:
 40 yr old female came to gen medicine department with chief complaints of fever since 3 days , cold since 4days complaints of cough with sputum , body pains since 3 days , headache since 3days, nausea since 1 day,vomiting since 1 day.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4 days back. Then she was developed cold and fever which is high grade and intermittent , associated with chills and rigor  relieve on taking medication ,cough since 4 days which is productive and mucoid in colour and scanty amount . Body pains since 3 days  and  headache since 3days . Nausea since 1day and vomiting since 1 day with 3 episodes , non projectile, non bilious , food as content.       She went to RMP and took  unknown medication  but her symptoms were not come down so she came to kims hospital and she was admitted. 
Past illness:
No h/o burning micturition , chest pain ,Short ness of breath ,  abdominal pain , dark coloured stools .
No h/o DM, HTN, , epilepsy ,asthma
H/o Tb  10 yrs back  complete 6 months course taken. 


Personal history:
Married 
Diet: mixed
Appetite: decreased 
Bowel movements: normal
Bladder movements: normal
Sleep: normal
Addictions: alcohol - regular.
                  
Family history:
Not k/c/o DM HTN asthma 
Stroke to patients  mother
Tb to patients father( expired 20 yrs back )
General examination:
pallor 
No  icterus 
No cyanosis
No lymphadenopathy
No clubbing 
No oedema of feet
Temperature: 104 F  
Pulse rate: 108/ min
Respiration rate: 32 per min 
Bp: 110/70 mm Hg
Spo2 97%
GRBS 222mg %
Systemic examination:
CVS
No thrills 
S1S2 present
No murmurs
Respiratory examination:
No dysnopea
No wheezing
Position of trachea is central
Breath sounds are vesicular
Abdominal examination:
Shape of abdomen- scaphoid
No tenderness
No palpable mass
Hernial orifices are normal
No free fluid
No bruits
Liver not palpable
Spleen not palpable
Bowel sounds no
CNS
llevel of consciousness- conscious
Speech normal
Signs of meningeal irritation:
    a) no neck stiffness
    b) no kernigs sign
Cranial nerves normal 
motor system normal
Sensory system normal
Glass gow scale normal 15/15
Reflexes
All are normal
Provisional diagnosis: 
Dengue NS1 POSITIVE
Treatment:
IVF 2 ONS 2 ORL
Inj . NEOMAL 1g iv stat
Tab. DOLO 650 mg TID
Tab. PANTAPRAZOLE 40 mg OD
Plan of care : conservative




Comments

Post a Comment

Popular posts from this blog

A 65 year old POSTURAL DIZZINESS AND VOMITING

Image
65Year old female POSTURAL DIZZINESS AND VOMITING December 03, 2023 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. This E log book also reflects my patient-centered online learning portfolio.   63 year old housewife from Nalgonda  Chief complaints- Vomiting 5 episodes 3 days ago History of present illness-  Patient was apparently alright 1 year back then developed vomiting associated with giddiness and pain. she came to our hospital and vomiting subsided with treatment. She was asked to take Vertin 24 (betahistine) at discharge. she took the medication for 3 months and then stopped after consulting with her physician. She had mild episodes of vomi
Read more

case 2

Image
Name: A. Greeshma  Roll no : 148 Introduction:   65yrs old male came to gen medicine department with chief complaints of bilateral pain and swelling since 10 days , bilateral loin pain since 10 days, fever and chills since 8 days ,bilateral pain in inguinal region since  5 days ,loose stools since 3 days . HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 10 days back ,then he developed complaints of  bilateral pedal edema pitty type associated with pain and redness with local rise in temperature .he also had bilateral loin pain 10 days  back later he had complaints of fever associated with chills, intermittent,no diurnal variation since 5 days ,he had complaints of pain in  bilateral inguinal region  for which with all above complaints he was taken to hospital and was diagnosed as AKI on CKD  with bilateral lower limb cellulitis , he also had loose stools 3 days back  watery not associated with blood   which resolved now . HISTORY OF PAST ILLNESS: History of blood urine
Read more