medicine e log by NIKITHA

CBBLE UDHC SIMILAR CASES

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

  Feb 8,2022

A 50 year male farmer brought  to casualty in stuporous  state with 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,then he developed pain abdomen in epigastric region associated with 3 episodes of vomitings-food particles as content.

Constipation present since 3 days,passing flatus.

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

BOWEL - CONSTIPATION SINCE 3 DAYS

BLADDER - REGULAR, ADDICTIONS-H/O  SMOKING 35yrs ago(2-3per day)- 

ALCOHOL-REGULAR INTAKE OF 90ML  SINCE 35YRS.

FAMILY HISTORY:Non-significant.

TREATMENT HISTORY: NON SIGNIFICANT 

 ON EXAMINATION -

PATIENT IS DROWSY , NO RESPONSE, NON COOPERATIVE

ICTRUS -PRESENT

 NO PALLOR

CLUBBING:ABSENT 

 NO  CYANOSIS , NO LYMPHADENOPATHY, NO  EDEMA

VITALS - 

TEMPERATURE - 102°F

 

PULSE RATE - 98BPM

BLOOD PRESSURE - 130/80 MM OF HG 

RESPIRATORY RATE - 22

SPO2 - 98% AT ROOM AIR

 

GRBS:132MG/DL

GCS-E3V2M4

PUPILS:NSRL

SYSTEMIC EXAMINATION - 

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : 

BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

P/A - soft,non tenderness 

, no organomegaly

CNS: 

Pt is DROWSY,NO RESPONSE,

non cooperative 

Neck STIFFNESS+,kernig sign+.

HMF: couldnot  be elicited.

Motor system:

Tone  -   Rt      Lt

U/L        N          N

L/L        N       N            

Reflexes:

Biceps

    

Investigations:

USG ON 8/2/22:

1.SURFACE IRREGULARITY WITH ALTERED ECHO TEXTURE OF LIVER.

2.GB WALL EDEMA

3.MILD ASCITIS.

LFT: TB-8.95                                                     DB-3.85 ,AST-64,ALT-190,ALP-319,TP-4.7,ALB-2.77,A/G-1.44

PT-20,INR-1.4,APTT-38

RFT: UREA-49,CREAT-0.9,URIC ACID-2.8,CA++-7.7,K+-2.9,CL-96,Na-140

CUE-NORMAL                     

SEROLOGY:NEGATIVE 

ABG: suggestive of RESPIRATORY alkalosis may be due to anxiety.

pH-7.51

pCO2-27

pO2:85.5

HCO3:21.2

LACTATE:3.50

Opthamology referral was done.

Findings in left eye:

Lids-discharge at canthus

Conjunctiva- early inflammed nasal pterygium

Mild congestion +

Cornea-clear

Sclera-yellowish discoloration +

PROVISIONAL DIAGNOSIS: ?DENGUE ENCEPHALITIS 

TREATMENT:

1.IVF-NS,RL@100ML /HR

2.INJ.MONOCEF 1 GM /IV/BD

3.INJ.ZOFER 4MG/IV/TID

4.INJ.THIAMINE 2 AMP IN 100ML NS/IV/STAT

5.INJ.NEOMOL 1 GM/IV/STAT

6.TAB.PCM 650MG/PO/TID

7.SYP.LACTULOSE 20ML/PO/TID

8.PROCTOLYTIC ENEMA-P/R-TWICE DAILY

9.INJ.DOXYCYCLIN E 100MG/IV/BD

10.INJ.VIT K 10MG IV_OD

11.INJ.PAN 40 MG /IV/BD

Day-1 ICU BED-2

soap notes.

50YEAR/male

S-C/O ALTERED SENSORIUM

O-

O/E:Icterus-present/ No pallor/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema

Temp:96.1

PR:75bpm

BP:140/80 mm of hg

RR:24cpm

CVS:S1,S2 heard,no murmurs

RS:BAE+,NVBS heard

P/A:SOFT,NONTENDER

A- ?DENGUE ENCEPHALITIS 

P-

1.IVF-NS,RL@100ML /HR

2.INJ.MONOCEF 1 GM /IV/BD

3.INJ.ZOFER 4MG/IV/TID

4.INJ.THIAMINE 2 AMP IN 100ML NS/IV/STAT

5.INJ.NEOMOL 1 GM/IV/STAT

6.TAB.PCM 650MG/PO/TID

7.SYP.LACTULOSE 20ML/PO/TID

8.PROCTOLYTIC ENEMA-P/R-TWICE DAILY

9.INJ.DOXYCYCLIN E 100MG/IV/BD

10.INJ.VIT K 10MG IV_OD

11.INJ.PAN 40 MG /IV/BD

LP DONE.