General medicine case - 6

 This is an online elog book to discuss our patient de-identified health data shared after taking his/her /guardians signed informed consent.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evident based inputs.

Chief complaint: 

A 45 yr old female patient, came to the casualty with the chief complaint of fever , shortness of breath, cough and body pains, pain in the abdomen since 5 days.

History of present illness: 

The patient was apparently asymptomatic before 5  days she then developed low grade fever associated chills and rigors, dry cough. No  vomitings, no loose stools , no burning micturation. She developed SOB grade 3.

Past history: 

No relevant past history. 

Patient is not a known case of diabetes/hypertension/asthama/epilepsy.

Family history:

No relevant family history.

Personal history:

Diet: mixed

Appetite: inadequate

Sleep : inadequate

Pernicious habits: no such habits

General examination: patient is conscious, coherent, cooperative, well associated with time and place.

No pallor, cyanosis, clubbing. 

Vitals:

Temp: 100F

Spo2: 96%

PR: 120bpm

RR: 30cpm

BP: 110/70mmhg

Fever chart:


Systemic examination:

CVS: S1 S2 heard, no murmurs

CNS : NAD

P/A : soft, non tender.

RS: BAE+,B/L IAA,IAM crepts.


Investigations:

Complete urine examination:

Albumin+

Ec: 2 to 3

Pc: 3-4

Bs: negative

Bp: negative

Sugar: negative

Blood urea: 90

Serum creatinine-1.1

Na+ : 139

K+: 4.8

Cl :95

Liver function test:

TB : 7.01

DB : 3.01

AST : 111

ALT : 75

ALP: 403

TP : 6.3

ALB : 2.0

ABG:

PH : 7.37

Pco2 : 53.3

Po2: 38.1

Hco3: 30.3

S.T Hco3: 26.7

Liver function test:

DB-3.10

TB-7.0

AST- 111

ALT:75

ALP-403

TP-6.3

ALB: 2.0

MP - negative

HIV- negative

HBSAG- negative

HCV- negative

Rapid dengue: negative

RTPCR: negative.










Provisional diagnosis: 

Viral pyrexia with thrombocytopenia,viral pneumonia, sepsis with mods.


Plan of treatment 
1. Ivf NS/RL/DNS continuous at 100ml/hr
2. Inj. PAN 40mg IV BD 
3. inj. ZOFER 4mg IV/SOS
4. Inj. NEOMOL 1gm IV/SOS
5. Inj. PIPTAZ 4.5 gm IV TID
6. Tab. PCM 650 mg PO/ SOS
7. Inj. OPTINEURON 1 AMP in 100ml NS IV/OD
8 Tab. TUSQ 1 tab PO BD
9. SYP. ASCORYL-LS 10ml PO TID
10. NEB. IPRAVENT 6th hourly 
NEB. BUDECORT 12th hourly
11. BP/PR/TEMP monitoring 4th hourly 
12. GRBS charting 12th hourly.
13. Intermittent CPAP if not maintaining on O2 
14. Syp. LACTULOSE 10 ml PO TID








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