A 52 year old male with pyrexia and ascites
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.
FINAL EXAMINATION LONG CASE REPORT:
2017
CASE HISTORY :
52 year old male,farmer by occupation, resident of Nalgonda came to hospital with chief complaints of:
• Fever since 7 days.
• Abdominal tightness since 7 days.
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 7 days ago then he developed
fever which was insidious in onset, gradually progressive, continuous, low grade fever ,without any chills and rigors
Relieved by medication ( paracetamol) ,no aggravating factors
Antonio tightness is present since 7 days which was insidious in onset
Not associated with pain,vomitings or diarrhea
Generalised weakness since past 7 days
No history of headache, bodypains, joint pains, abdominal pain
No history of vomitings, diarrhea
No history of bleeding tendencies
PAST HISTORY :
No similar complaints in the past
No history of diabetes, hypertension, asthma, tuberculosis, epilepsy, coronary artery disease,CVA
PERSONAL HISTORY :
Diet - Mixed.
Appetite- decreased for the past 5 days.
Sleep - adequate.
Bowel and bladder movements - regular.
Addictions: takes alcohol and toddy occasionally since 15 years.
History of Toddy intake 7 days back.
FAMILY HISTORY :
insignificant
GENERAL EXAMINATION :
Patient is examined after taking informed consent in a well lit room
Patient is conscious,coherent,cooperative, well oriented to time ,place and person and moderately built and moderately nourished
No signs of pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema
VITALS:
Pulse rate : 90 bpm
Respiratory rate : 20cpm
BP : 120/80 mm hg
SpO2 : 98%
Grbs - 110mg/dl
SYSTEMIC EXAMINATION :
PERABDOMEN EXAMINATION :
INSPECTION :
Abdomen is distended
Flanks -full
Umbilicus is normal
No visible scars, sinuses, pulsations,engorged veins over abdomen
No visible peristalsis
PALPATION :
abdomen is distended, organs couldn't be palpated
PERCUSSION :
fluid thrill is present
AUSCULTATION : normal bowel sounds heard
RESPIRATORY SYSTEM EXAMINATION :
Bilateral air entry present
Normal vesicular breath sounds heard
CVS EXAMINATION :
S1, S2 heard, no murmurs
CNS EXAMINATION :
Normal, no abnormality detected
INVESTIGATIONS :
ON 8/06/22
On 8-6-22
Hemogram was done
Hemoglobin - 14.9 gm/dl.
Tlc- 10,500cells/ mm³.
Neutrophils- 43%
Lymphocytes- 48%.
Eosinophils - 01%.
Platelet count - 22000 cells/ cumm.
PCV - 42.2
Blood urea-59 mg/dl
Serum creatinine -1.6mg/dl
Serum electrolytes:
Na-142 mEq/l
K-3.9mEq/l
Cl-103 mEq/l
Liver function tests-
Total bilirubin-1.27 mg/dl
Direct bilirubin-0.44 mg/dl
SGOT-60 IU/L
SGPT-47IU/L
ALP-127IU/L
Total proteins- 5.9 gm/dl
Albumin-3.5g/dl
A/G ratio-1.48
CUE:
Albumin ++
Pus cells - 4-6
Epithelial cells - 2 -3.
NS 1 ANTIGEN Test - Positive.
IgM and IgG - Negative.
HIV RAPID TEST non reactive.
HBsAg Rapid test - negative.
Anti HCV antibodies - non reactive.
USG report:
Mild splenomegaly .
Right sided mild pleural effusion.
Mild ascites.
Grade 2 fatty liver.
Gall bladder wall edematous.
On 9-6-22:
Hemogram:
Hemoglobin: 14.3gm/dl.
Wbc - 8200 cells/cumm
Neutrophils - 38%
Lymphocytes-51%.
Platelet count - 30,000/cumm.
PCV - 42.0
On 10-6-22
Hemogram:
Hemoglobin- 14 gm/ dl
Tlc - 5680cells/cumm.
Neutrophils -35%
Lymphocytes - 54%.
Platelet count-84,000/cumm.
Serum creatinine- 1.2 mg/dl.
On 11-6-22
Hemogram:
Wbc- 4800 cells/cumm.
Neutrophils - 40%
Lymphocytes-48%
Platelet count -60,000cells/cumm.
On 11-6-22 evening
Platelet count -76000cell/cumm.
On 12-6-22
Hemogram
Hb-15.3
Wbc - 7,100.
Neutrophils - 40%
Lympocytes -50%
Platelet count- 1 lakhcells/cumm.
PCV - 44.6
PROVISIONAL DIAGNOSIS :
Viral pyrexia with thrombocytopenia secondary to dengue NS1 positive with polyserositis ( with right sided pleural effusion with mild ascites)
TREATMENT :
On 8-6-22
Ivf NS/RL/DNS continuous at 100ml/hr
Inj. PAN 40mg IV BD
inj. ZOFER 4mg IV/SOS
Inj. NEOMOL 1gm IV/SOS
Tab. PCM 650 mg PO/ SOS
Inj. OPTINEURON 1 AMP in 100ml NS IV/OD over 30mins.
On 9-6-22
Treatment
Iv fluids - Ns/RL @100 ml/hr
Inj.pan 40 mg iv/OD
Inj.optineuron 1 amp in 100 ml/Ns/iv/OD over 30 mins
Inj.zofer 4mg/iv/sos
Tab.doxycycline 100mg PO/BD
VITALS monitoring
On 10-6-22
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 4mg iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
VITALS monitoring 4 th hourly.
On 11-6-22
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 4mg iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
DOLO 650mg /sos
VITALS monitoring.
On 12-6-22
Iv fluids - NS,RL@50 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 4mg iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
DOLO 650mg /sos
VITALS monitoring.
On 13-6-22
Oral fluid
Tab.dolo650mg/po/sos.
Tab.pan 10mg/po/od.
Tab.doxycycline 100mg/po/bd.
Tab.zincovit po/od
Vitals monitoring.
On 14/06/22
Oral fluids
Tab. Dolo 650 PO/SOS
tab. PAN-D (40/10) PO/OD
Tab. DOXYCYCLINE 100mg PO/BD
tab. ZINCOVIT PO/OD
vitals monitored 8th hourly
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