A case of 33year old male
Name: J. Akash
7/01/2023
Roll no. 53
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.
Following is the view of my case :
patient came with complaints of fever since 6days
fever with chills and rigors ,high grade intermittent fever associated with body pains and bilateral lowerlimbs pain .
3 episodes of vomitings ,non-projectile,non-bilious ,non-blood staining relieved with taking injection.
Dark coloured urine accompanied with bilateral lower limbs edema pittng type, generalised swelling progressively increased.
Yellowish discoloration of sclera and skin over chest and hands since 3days
Constipation since 3days
3days ago blood investigations were done and noticed dropping of platelets count. Outside investigation NS-1 negative
No h/o weight loss
No h/o dyspnea, orthopnea,PND,
No h/o chest pain ,chest tightness.
No h/o headache, seizures ,dizziness.
No h/o Cough, cold.sorethroat
No h/o loose stools, abdominal distension , burning micturition.
PAST HISTORY:
No H/o DM/HTN/THYROID/CAD/EPILEPSY/TB/ASTHMA
PERSONAL HISTORY:
apetite -normal
diet-mixed
sleep-adequate
Bowel&bladder- regular
Addictions: alcoholic since 10years
smoking since 10years
No significant family history
GENERAL EXAMINATION:
pt conscious/coherent/co-operative
well orientated to time place person
Mucosal rash :
Mucosal rash , no cutaneous rash
Icterus present
Skin - yellow
No signs of pallor, clubbing, cyanosis, lymphadenopathy
Bilateral pedal edema
Vitals:
BP-120/70 mm hg
PR-84bpm
GRBS-111mg/dl
Skin-yellow
SYSTEMIC EXAMINATION:
CVS- S1 S2 heard
No thrills and murmurs
RS- BAE+
Trachea central
Abdomen: Shape-scaphoid
No tenderness
No palpable mass
Liver and spleen not palpable
CNS: conscious &alert
No focal deficit
INVESTIGATIONS:
Hemogram:
Hb-9.7
TLC-12,600
PLT-34000
RBC-3.57
TB-15.1
DB-14
Na-116
K-4.6
Cl-87
Dengue NS1 - Non-reactive
Coombs Test:
ECG:
Chest Xray:
07/01/2023
09/01/2023
USG-Abdomen
PROVISIONAL DIAGNOSIS : Viral pyrexia with thrombocytopenia with hepatitis with AKI with Acute liver injury
TREATMENT GIVEN:
1)IVF NS @100ml/hr
2)syp.lactulose 15ml po/TOD
3)inj pan 40mg IV/BD
4)Tab.Dolo 650 mg po/TID
5) protein powder 1scoop in 100ml Milk po/BD
07/01/2023
UNIT 5
DR HIMAJA, PGY1
DR PAVANI, PGY2
DR SAICHARAN, PGY3
DR ABHINAYA, SR
DR AKASH, INTERN
DR HYNDAVI, INTERN
AMC, DAY 1
AGE : 33Y GENDER :M
S:
No fever spikes
Stools not passed
No vomitings
O:
pt conscious, coherent, co-operative
Bp-120/80mmhg
PR-82bpm
Temp-98°FF
GRBS-111 mg/dl
SPO2-97%
RS- BAE+ ,NVBS
CVS-S1 S2 heard
P/A - soft,NT
CNS-HMF intact
memory -normal
A:
pyrexia with thrombocytopenia
with AKI with acute liver injury ?leptospirosis
P:
IVF NS @100ML/HR
Inj.Doxy 100mg BD
Tab.Dolo 650mg po/TID
Syp. Lactulose 15ml Po/TID
protein powder 1scoop in 100ml Milk po/BD
Tab.udiliv 300mg po/BD
Monitor vitals
08/01/2023
UNIT 5
DR HIMAJA, PGY1
DR PAVANI, PGY2
DR SAICHARAN, PGY3
DR ABHINAYA, SR
DR AKASH, INTERN
DR HYNDAVI, INTERN
AMC, DAY 2
AGE : 33Y GENDER :M
S:
No fever spikes
Stools not passed
Flatus +
O:
pt conscious, coherent, co-operative
Bp-110/80mmhg
PR-80bpm
RR-16cpm
Temp-98°FF
GRBS-123 mg/dl
SPO2-97%
RS- BAE+ ,NVBS
CVS-S1 S2 heard
P/A - soft,NT
CNS- No focal deficit
I/O - 2050/3000ml
A:
Fever with thrombocytopenia
with AKI with acute liver injury ?leptospirosis
P:
IVF NS @100ML/HR
(D2)inj Doxycycline 100mg BD in 100ml NS
Syp. Lactulose 15ml Po/TID
protein powder 1scoop in 100ml Milk po/BD
Tab.udiliv 300mg po/BD
Tab.Dolo 650mg Po/Sos
(D1)Inj.Vit k 1amp in 100ml NS
09/01/2023
UNIT 5
DR HIMAJA, PGY1
DR PAVANI, PGY2
DR SAICHARAN, PGY3
DR ABHINAYA, SR
DR AKASH, INTERN
DR HYNDAVI, INTERN
AMC, DAY 3
AGE : 33Y GENDER :M
S:
No fever spikes
Stools passed
1 episode of vomiting
mucosal rash present
skin yellowish discoloration present
O:
pt conscious, coherent, co-operative
Bp-110/80mmhg
PR-82bpm
RR-16cpm
Temp-98°FF
GRBS-101 mg/dl
PLT-69000
LFT - TB-27
DB-23
AST-134
ALT-176
ALB-2.6
SPO2-97%
RS- BAE+ ,NVBS
CVS-S1 S2 heard
P/A - soft,NT
CNS- No focal deficit
A:
Fever with thrombocytopenia
with AKI with acute liver injury ?leptospirosis
P:
IVF NS @100ML/HR
(D3)inj Doxycycline 100mg BD in 100ml NS
Syp. Lactulose 30ml Po/TID
protein powder 1scoop in 100ml Milk
Tab.Dolo 650mg Po/Sos
Tab.udiliv 300mg po/BD
Inj.Thiamine 200mg IV/TID
(D2)Inj.Vit k 1amp in 100ml NS
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