Skip to main content

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

Comments

Post a Comment

Popular posts from this blog

A 45 YEAR  FEMALE WITH FEVER, VOMITING AND SHORTNESS OF BREATH 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 patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is 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. A 45year female Presented with  C/O Fever since 5 days C/O Vomiting since 4 days C/O Headache since 4 days C/O Shortn
Post a Comment
Read more
  BIMONTHLY ASSIGNMENT OF MEDICINE FOR AUGUST 2021 BELOW IS THE LINK TO THE QUESTIONS ASKED TO US:- http://medicinedepartment.blogspot.com/2021/08/medicine-paper-for-aug-2021-bimonthly.html QUESTION 1:- Below is the link of the student for which I am giving my peer review. https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006003-case-presentations.html?m=1 LONG CASE  :- A 44 year old man presented with a 3-day history of bilaterally symmetrical rapidly progressive generalized edema. REVIEW:- *The Case is well presented and  p atient data has be deidentified and privacy is marked. *C ase history is taken beautifully precisely taken including social ,educational and surgical  history which is way too essential to understand the socio economic back ground of the patient and helpful in accurate diagnosis. FINAL DIAGNOSIS : - *Acute Glomerulonephritis, likely due to Secondary Amyloidosis due to Chronic Poorly Treated Seronegative Erosive Rheumatoid Arthritis. *Dilutional Hypona
Post a Comment
Read more
  BIMONTHLY ASSIGNMENT OF MEDICINE FOR JULY 2021 BELOW IS THE LINK TO THE QUESTIONS ASKED TO US:- http://medicinedepartment.blogspot.com/2021/07/medicine-paper-for-july-2021-bimonthly.html?m=1 QUESTION 1:- Below is the link of the student for which I am giving my peer review. https://www.google.com/url?q=https://www.google.com/url?q%3Dhttps://angasanvith09.blogspot.com/2021/07/general-medicine-assignment.html%26amp;sa%3DD%26amp;source%3Deditors%26amp;ust%3D1626285857750000%26amp;usg%3DAOvVaw1I_MGzhIo0PPVtxipHNTa3&sa=D&source=editors&ust=1626285858217000&usg=AOvVaw1DbqqMfufy_38kPpzIaX2r Reviews to all the questions answered:- 1) The reviews for the cases selected are well described. A detailed pinpoint review has been given to each particular case selected, which is helpful in easy analysis.  Even though the peer reviews giving are short they are well described. 2)He  went with good investigations and given a better explanation for every case. Even every  investigation a
Post a Comment
Read more