Case history-6


A 45 year old male presented to opd with Chief complaint - 


 fever and chills since 4 days . 


HISTORY of Present illness- 

Patient was apparently asymptotic well 4 days back 

Patient complaints of high grade fever with mild continuous head ache

He referred to local hospital 1 day later 

Patient complaints of muscle cramps during initial days they is decreased platelet count. 

No history of vomitings and loose stool


HISTORY OF PAST ILLNESS:-



Not a known case of hypertension, diabetes, asthma, epilepsy, tuberculosis.


PERSONAL HISTORY:-


Patient takes mixed diet, decreased appetite

sleep adequate. 

Bowel and bladder habits are regular.

No addictions.

Patient is married and has 2 children.


Medical history 

No drug allergies. 


 Family history:

No similar complaints of family 


GENERAL EXAMINATION:-


On examination: 

Patient is conscious, coherent and cooperative .

He is well built and examined in well lent room


Vitals-

Temp: afebrile

PR: 70 bpm

BP: 130/90 mm hg

RR: 24 cpm

SPo2 - 98% 


No Pallor 

No Icterus

No signs of cyanosis, clubbing, koilonychia. 

Dehydration- present 



PER ABDOMEN: soft, non tender

CVS: S1S2 heard

RS: BAE +, NVBS+

CNS: NAD 











Provisional diagnosis:
Viral pyrexia with thrombocytopenia 

Treatment:

26/10/21 and 27/10/21 - 
IVF -Normal saline @ 100ml/ hr 
INj PAN  40mg IV OD 
Inj Oppineuron 1 amp IV OD 
Inj. Taxim 1g IV BD

28/10/21 - 
IVF -Normal saline @ 100ml/ hr 
INj PAN  40mg IV OD 
Inj Oppineuron 1 amp IV OD 
Inj. Taxim 1g IV BD

Fever subsided  with strict charting , plenty of oral fluids . Temperature, BP , PR monitoring 4th hrly .


 

Comments

Post a Comment

Popular posts from this blog

Short case final general medicine

Image
  Date of Admission- 05 -02-22 A 25 year old Male presented to OPD with chief complaints of  vomitings 10 episodes and bipedal edema and decreased Urinary output since 3 years .  HISTORY OF PRESENT ILLNESS Patient was apparently asymptomatic 3 years ago then  he developed multiple episodes of vomitings for which he was admitted in the hospital and found to have high BP of 170 mm Hg .  HISTORY OF PAST ILLNESS  Known history of hypertension . Known history of Tuberculosis  No history of Diabetes mellitus asthma, epilepsy. No history of surgeries, chemotherapy or radiotherapy  PERSONAL HISTORY  Diet - Mixed   Appetite- Normal  Bowel movement is regular . Micturition - Normal  Addictions- None  Sleep  - Regular  FAMILY HISTORY   No history of DM, CAD, Asthma and thyroid disorders in the family GENRAL EXAMINATION  Patient is conscious, coherent, co-operative. There are no signs of icterus, clubbing, pallor, cynosis, lymphadenopathy VITALS Temperature- 98.4   Pulse rate-  78 bpm Respiratory
Read more
Image
A 56 year male  patient workers in food center presented to opd with complain of swelling in leg and abdomen since 7 days ago. History of present illness: Patient was apparently asympmatic one month back .he then developed swelling in legs with no pain.they is gradually increase in swelling from legs to abdomen after 2 days . Patient develops pedal edema of pitting type grade -1 . After 10 days it is progressed to grade -2 Over 15 days pitting type grade 3 Patient has no complaints on fever, vomiting . Past history: 1.Patient is suffering with hypertension since 3 month .he is undergoing into medication immediately  2.no diabetes, no seizures,no epilepsy,no tuberculosis,no thyroid disorder  3.patient had not undergone any surgeries  4.patient had suffered from pulmonary koch’s 22 yrs back .patient has used ATT for 6 months. Personal history:  1.diet- mixed  2.appetite- normal  3 .bowel amd bladder movement- normal  4 . Sleep- normal  5. Addictions - no smoking and no alcohol consumptio
Read more

Final pratical exam long case

Image
Feb 8,2022 A 50 year male farmer brought  to casualty with chief complaints of  -pain abdomen since15 days -Loss of appetite since 10 days -H/o fever since 3days. -h/o vomitings since 3 days -h/o constipation since 3 days -h/o altered sensorium since 3 days -h/o yellowish discoloration of urine since 2 days. HISTORY OF PRESENTING ILLNESS - Patient was apparently asymptomatic 15 days ago, he is a chronic smoker and daily alcohol consumption from past 35 yrs.  he developed pain abdomen in epigastric region from past 15 days, associated with 3 episodes of vomitings-food particles as content. With severe abdominal pain at lower part Patient also suffered with constipation from past 3 days. From past 3 days he developed altered sensorium. Yellowish discolouration in urine is seen from past 2 days. PAST HISTORY -  Not a K/C/O DM, HTN,CVA,CAD,COVID-19. DIAGNOSED AS DENGUE IgM POSITIVE ON 2/2/22-AND TREATMENT  TAKEN PERSONAL HISTORY : DIET - MIXED, APPETITE -LOSS OF APPETITE SINCE 10 DAYS BOWE
Read more