Medicine AMC case

 This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.


Tuesday,December 14th 2021

A 24yr old male came with complaints of fever and Stomach pain.


B.Sushma ,9th semester

Roll no.154

December 14th,2021


A CASE DISCUSSION ON FEVER AND STOMACH PAIN.


I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.


CASE PRESENTATION:


A 24yr old male, worker by occupation presented to our opd on 11th december 2021 with

CHEIF COMPLAINTS of

  • Fever since 1week 
  • Stomach pain since 1week
  • Black coloured stools since 2days
  • Giddiness since 1day

  HISTORY OF PRESENT ILLNESS:

  • Patient came with c/o high grade fever since 1 week associated with chills intermittent,went to RMP and took some injections later fever subsided 1 day ago.
  • Stomach pain since 1week not associated with vomitings or any loose stools or constipation.
  • C/o black coloured stools since 2 days
  • C/o giddiness since 1 day.
  • C/o itchy scaly skin lesions on left side of face since 1day.
  • No c/o vomiting,loose stools,cold, cough, shortness of breath, burning micturition,rashes, body pains.

PAST HISTORY:      

  •  not a k/c/o DM,HTN,CAD
  • Not a known case of Asthma , Epilepsy 

PERSONAL HISTORY:

Appetite: Normal

Diet: Mixed 

Bowel and bladder movements: Regular 

Urine output : Normal

Addictions: not present


FAMILY HISTORY:

Not significant


GENERAL EXAMINATION: 

Patient is conscious, coherent and cooperative.

He is well oriented to time, place and person. 

He is  moderately nourished.


 Pallor-Absent


No Icterus


No Cyanosis


No Clubbing


No Lymphadenopathy


Edema -absent

VITALS: 

Temperature:98F

Pulse rate:98/min

Respiration rate:16 cycles /min

Bp:110/80mmHg

SpO2 at room air:98%

SYSTEMIC EXAMINATION:

Respiratory System- BAE+ clear

Normal vesicular breath sounds heard.

CVS- S1 and S2 heard 

CNS- 

Higher mental functions intact 

Cranial nerves intact 

Kernings sign negative

Neck stiffness absent

Level of consciousness normal

Speech normal

.ABDOMEN-

On Inspection:

  • Shape-Normal
  • No visible scars,orifices

On Palpation:

  • Soft and non tender
  • No palpable mass
  • Liver and spleen not palpable

On auscultation:

  • Bowel sounds heard

On percussion:

  • Dull note is heard

REFLEXES-

Present 

Clinical pictures:






INVESTIGATIONS:

ECG


CHEST x-ray


Fever chart


USG




RBS






CUE



LFT


HEMOGRAM


Provisional diagnosis :-

 Dengue fever with thrombocytopenia ( NS + ) 

Treatment :- 

 (11/12/2021) 

1) IVF NS,RL,DNS- @100 ml/hr.

2) Inj pantop 40 mg IV OD

3) W/F postural hypotension, bleeding manifestations

4) tab doxycycline 100 mg po BD

5) Inj optineuron 1 amp IV OD in 100 ml DNS

6) BP,PR 4th hourly

7)  Temp charting 4th hourly

8)  GRBS 12th hourly.

(12/12/2021):-

IVF NS,RL,DNS- @100 ml/hr.

 Inj pantop 40 mg IV OD 

doxycycline 100 mg po BD

 Inj optineuron 1 amp IV OD in 100 ml DNS

 BP,PR 4th hourly

 Temp charting 4th hourly

 GRBS 12th hourly.

(13/12/2021):-

IVF NS,RL,DNS- @100 ml/hr.

 Inj pantop 40 mg IV OD 

doxycycline 100 mg po BD

 Inj optineuron 1 amp IV OD in 100 ml DNS

 BP,PR 4th hourly

 Temp charting 4th hourly

 GRBS 12th hourly.

(14/11/21):-

IVF NS,RL,DNS- @100 ml/hr.

 Inj pantop 40 mg IV OD 

doxycycline 100 mg po BD

 Inj optineuron 1 amp IV OD in 100 ml DNS

 BP,PR 4th hourly

 Temp charting 4th hourly

 GRBS 12th hourly.

Dermatology consultation  

 It is a known case of dengue fever with thrombocytopenia complaint of itchy scaly skin lesion on left side of face, beard since 1 day 

no history of application of any topical medication 

no history of similar complaints in the family 

On examination 

multiple well defined erythematosis scaly annular plaques on right cheek beard area tinea faciei 

Treatment 

Lulican cream BD for two weeks



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