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.

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