CASES IN GENERAL MEDICINE

A 70yr old male, Agriculture by occupation was brought to casualty in an unconscious state since yesterday.

Hi, I am Ankesh Kumar Sahu is a medical student. This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. This E-log book also reflects my patient-centered online learning profile and your valuable inputs on the comment box are welcome. 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.

CHIEF COMPLAINTS:-

*Fever since 3 days

*Abdominal pain(Burning type) since 3 days

HISTORY OF PRESENT ILLNESS:-

*Patient was apparently asymptomatic 1 week back after which he started binge

drinking for 2 days.

*Then he developed Fever that last for 3 days and developed Abdominal pain Burning type both for which he was treated by local Doctor.

*After that he developed weakness which is gradual in onset and was unable to stand for which he was admitted to local hospital where he was diagnosed to have DENGUE FEVER (through NS1 ANTIGEN Positive) and the Platelet Count was 24,000.

PAST HISTORY :-

*Chronic Alcoholism since 30 years and increased his intensity since last 3 years.

*Smoking since 20 yrs, average2 beedi per day.

TREATMENT HISTORY :-

*No History of any Treatment

PERSONAL HISTORY :-

*He is Chronic alcoholic since 30 years

*Chronic smoker since 20 years

FAMILY HISTORY:-

*No Familial history

GENERAL EXAMINATION:-

*Patient was in an Unconscious state

*No Icterus and pallor

*No B/l pedal edema

*No lymphadenopathy

ON EXAMINATION:-

*BP: 90/60mmhg

*PR: 102bpm

*GRBS: 34mg/dl

*Temperature: 99°F

*RR: 36cpm

*SpO2: 85% with 4 Liters of O2

*Severe Thrombocytopenia with Bleeding Manifestations (Epistaxis)

INVESTIGATIONS:-

CBP:-

CUE:-

*COLOUR: Pale Yellow

*APPEARANCE: Clear

*REACTION: Acidic

*SP GRAVITY: 1.010

*ALBUMIN: +

*SUGAR: Nil

*BILE SALTS: Nil

*BILE PIGMENTS: Nil

*PUS CELLS: 4-6

*EPITHELIAL CELLS: 2-4

*RED BLOOD CELLS: Nil

*CRYSTALS: Nil

*CASTS: Nil

*AMORPHOUS DEPOSITS: Absent

*OTHERS: Nil

APTT:-

* APTT TEST: 32 Sec

PROTHROMBIN TIME:-

*PT: 16 Sec

# INR: 1.1

# BLEEDING TIME: 2 min

# CLOTING TIME: 4 min 30 sec

BLOOD SUGAR RANDOM:-

SEROLOGY:-

HIV 1/2 RAPID TEST:-

HBsAg-RAPID:-

Anti HCV Antibodies-RAPID:-

LFT:_

RFT:-

BLOOD GROUPING AND RH TYPE:-

ABG:-

CHEST RADIOGRAPHY:-

PROVISIONAL DIAGNOSIS:-

*Dengue shock syndrome

(??Dengue encephalitis)

*With hepatitis SECONDARY to Dengue? Alcohol??

*With Pre renal AKI

TREATMENT:-

1. 25% Dextrose for Hypoglycemia

2. IVF. NS Bolus 1 Liter

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