General medicine case
A 45 year old female patient with fever, generalized body pains, Shortness of breath and painful abdomen
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Case
A 45 year old female patient with fever and generalized body pains since 10 days and shortness of breath and pain abdomen since 5 days.
History of present illness:
The patient was apparently asymptomatic 10 days back before the standing illness. Then the started experiencing generalized body pains and fever since 10 days and shortness of breath and pain abdomen since 5 days.
When patient experienced fever and generalized body pains she visited RMP doctor and Medications were taken but fever didn't subside later patient started experiencing shortness of breath and pain abdomen where she was taken to miryalaguda and there it was told that patient has lung infection,liver infection and kideny infection and since there is no proper treatment facilities he came to kims.
Now patient's SOB has little bit relieved as per the patient
But she developed moderate cough which is not associated with sputum and is dry
On coughing patient was experiencing chest pain and is unable to speak in the night.
Before all these ,as patient was staying at home patient's daily routine was to wake early in the morning by 5'o clock and does the household work and have breakfast by 9 o'clock and lunch by 12 o'clock. Then dinner by 7 o'clock and sleeps by 8 o'clock.
10 years back patient was farmer by occupation and used to go to the field work daily.
Past history
No h/o HTN/DM/Epilepsy/TB/Thyroid disorders
Patient had hysterectomy 20 years back.
Patient had no h/o blood transfusion.
Personal history
Diet : mixed
Appetite : loss of appetite since 5 days
Bladder and bowel movements:normal
Sleep : disturbances since 5 days
No addictions
Family history
No history of DM/HTN/CVA/CAD/Asthma/thyroid disorders
No similar complaints in the family previously.
Treatment history
Not significant.
General examination
Patient is conscious, coherent and cooperative.
Oriented to time,place and person.
No pallor
Patient had icterus,no cyanosis,no clubbing,no lymphadenopathy.
Vitals
Temp - 100 F
PR- 120 bpm
BP- 90/60 mmHg
RR- 40 cpm
SpO2- 97%
Systemic examination:
CARDIOVASCULAR SYSTEM:
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge.
Palpation:
JVP: normal
Auscutation:
Normal with regular heartbeat
S1, S2 heard
No murmurs
RESPIRATORY SYSTEM-
Position of trachea: central
Normal Bilateral air entry
B/L IAA and IMA crepts
PER ABDOMEN:
Distended.
Tender
No mass is palpable.
No organomegaly
Bowel sounds+
CENTRAL NERVOUS SYSTEM:
Patient is Conscious, coherent and cooperative.
Provisional diagnosis:
Viral Pyrexia with Thrombocytopenia, viral pneumonia, sepsis with MODS.
Investigations on 17/12/21
Cue:
Albumin +
BS : negative
BP: negative
Sugar : negative
Blood cells and casts : negative
Blood urea: 90
Serum creatinine: 1.1
Na+ : 139
K+ : 4.8
Cl- : 95
LFT:
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
HIV : Negative
HBSAG : negative
HCV : negative
RAPID DENGUE : negative
RTPCR : negative
Investigations on 19/12/21
Hb: 9.3
Tlc: 20,800
Plt. Count : 3.73
Serum total bilirubin: 9.92
Direct bilirubin: 3.21
Serum creatinine : 0.7
Clinical images
2D ECHO
Ultrasound abdomen:
ECG on 17/12/21
Previous reports:
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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