LONG CASE:
CHIEF COMPLAINTS:
A 55 year old female, house wife by occupation came with chief complaints of
Fever since 5 days.
Neck stiffness since 5 days.
HISTORY OF PRESENTING ILLNESS:
-Patient was apparently asymptomatic 5 days back then she had fever which is sudden in onset and continuous type and relieved on medication.
-Complaints of bilateral knee joint pains
-Fever not associated with chills and rigors. No h/o cold ,cough ,loose stools , abdominal pain , breathlessness, PND , orthopnoea. No history of burning micturition, increased frequency of micturition.
-There is h/o headache from 25 days but it got aggravated since 5 days which is insidious in onset and progressive and not relieved on medication, No aggravating and relieving factors .
- History of neck stiffness since 5 days.
-History of vomiting 3 days back ,1 episode which is not projectile ,non bilious ,content is food particles .
Past history:-
No history of similar complaints in the past.
Medical illness - Not a known case of diabetes , hypertension, asthma, TB, Thyroid .
•7 yrs back she had history of CVA where both upper and lower limbs are paralysed and took some medication.
she took allopathy medicine 6 months back and she got recovered.
•Surgical history- hysterectomy done 25 yrs back .
Family history:-
No similar complaints inthe family
No history of diabetes, hypertension,TB ,asthma.
Personal history:-
Diet - mixed
Appetite - lost
Sleep - adequate
Bowel and bladder- regular bladder and constipation is present .
No addictions and allergies.
General examination:-
Patient is conscious, coherent, coperative. Moderately built moderately nourished.
No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, generalised edema.
Vitals:
Temperature: 99°F
Pulse rate: 75bpm
Resp rate:15cpm
BP:110/70mmhg
Spo2:96%.
Systemic examination:-
Central nervous system-
Higher mental functions
• conscious
• oriented to person and place ,time.
• memory - able to recognize their family members
• Speech - normal.
Cranial nerve examination -
• 1 - sense of smell present
• 2- Direct and indirect light reflex present
• 3,4,6 - no ptosis Or nystagmus
• 5- corneal reflex present on both sides
• 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present.
• 8- able to hear
• 9,10- uvula not deviated
• 11- sternocleidomastoid contraction present
• 12- no tongue deviation.
Motor system
Tone -. Upper limbs Lower limbs
Inspection - Normal Normal
Palpation - Normal Normal
Bulk : right Left
Arm 28cm 27cm
Forearm 20cm 18 cm
Thigh 33 cm 32cm
Calf 25 cm 23 cm.
Power :
Muscles of neck -
• stenocleidomastoid- good
•Nuchal muscles- stiffness present
Slight tenderness present over the neck on examination.
Right Left
Biceps- 5/5 5/5
Triceps-. 5/5 5/5
Brachioradialis-. 5/5 5/5
Tibialis posterior-. 5/5 5/5.
Reflexes: right left
Biceps- + +
Triceps- + +
Supinator- + +
Knee- + +
Ankle - + +
Sensory system: Normal
Cerebellar signs :
Knee - heel incoordination - No
Finger - nose incoordination- No
Meningeal signs -
Neck stiffness present .
Kernig's sign - positive
Brudzinki sign - positive.
EXAMINATION OF OTHER SYSTEMS
CARDIOVASCULAR SYSTEM:
S1 S2 Heart sounds – normal
No thrills/murmurs
RESPIRATORY SYSTEM:
Chest symmetrical, No paradoxical movements, Normal vesicular breath sounds heard,
No abnormal/added sound
ABDOMEN:
Abdomen is soft, non tender,No organomegaly, No ascites.
Provisional diagnosis:-
Dengue fever with viral meningo encephalitis under evaluation and detected denovo diabetes mellitus type 2.
Investigations:-
GRBS - 91 mg/dl
Hemogram :-
Hb - 13 g/dl
TLC - 3500
N/L/E/M-60/30/2/8
PLT- 2.1 lakh per mm3
NC/NC
Fasting blood sugar- 168 mg/ dl
Hb1 AC -6.9
Urea- 38
Serum creatinine- 1.0
Uric acid - 4.9
Sodium- 141meq
Pottasium- 4.0
chloride- 105.
Serology - non reactive
LFT:
Tb - 1.03
Db- 0.31
SGOT(AST) - 69
SGPT(ALT) - 68
ALP-135
Tp-6.4
Albumin-4.0
CUE:
Albumin +
Sugar - nil
Pus cells - 6 - 8
Epithelial cells- 3-4
RBC - nil
Casts - nil .
CSF :
Sugar - 81
Protein-12.6
Chloride-113
ABG:
pH - 7.4
Pco2- 29.1
Po2- 88.4
Hco3- 18.0
Sat O2 - 96%.
Treatment:-
Inj. CEFTRIAXONE 2 gm/ BD
Inj.DEXA 6mg/iv/tid
Inj . Vancomycin 1gm/iv
Inj. Pcm 1gm/iv
Tab . Pcm 650 mg
Tab. Ecospirin 75 mg /po/od
Tab. Atorvas 10 mg /po/od
Syp. Cremaffin plus 30ml/po
On day 2 :-
Patient is conscious, coherent, cooperative.
Vitals:-
Temperature: 99°F
Pulse rate: 76bpm
Resp rate:15cpm
BP:130/90mmhg
Spo2:96%
GRBS- 197mg/dl.
Treatment-
Inj. CEFTRIAXONE 2 gm/ BD
Inj.DEXA 6mg/iv/tid
Inj . Vancomycin 1gm/iv
Inj. Pcm 1gm/iv
Tab . Pcm 650 mg
Tab. Ecospirin 75 mg /po/od
Tab. Atorvas 10 mg /po/od
Syp. Cremaffin plus 30ml/po
Oint.Diclofenac for thigh pain.
On day 3:-
Patient is conscious, coherent, cooperative.
Vitals:-
Temperature: 99°F
Pulse rate: 78bpm
Resp rate:16cpm
BP:120/90mmhg
Spo2:96%
GRBS- 190mg/dl
Treatment-
Inj. CEFTRIAXONE 2 gm/ BD
Inj.DEXA 6mg/iv/tid
Inj . Vancomycin 1gm/iv
Inj. Pcm 1gm/iv
Tab . Pcm 650 mg
Tab. Ecospirin 75 mg /po/od
Tab. Atorvas 10 mg /po/od
Syp. Cremaffin plus 30ml/po
Oint.Diclofenac for thigh pain
Inj.pan 40 mg iv /od
Tab. Naproxen 250 mg po/tid.
Flexbenz gel for L/A on thighs.
Day 4:
Inj. CEFTRIAXONE 2 gm/ BD
Inj.DEXA 6mg/iv/tid
Inj . Vancomycin 1gm/iv
Inj. Pcm 1gm/iv
Tab . Pcm 650 mg
Tab. Ecospirin 75 mg /po/od
Tab. Atorvas 10 mg /po/od
Syp. Cremaffin plus 30ml/po
Oint.Diclofenac for thigh pain
Inj.pan 40 mg iv /od
Tab. Naproxen 250 mg po/tid.
Flexbenz gel for L/A on thighs.
Tab metformin 500mg/od.
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SHORT CASE:
A 22yr old male pt. painter by occupation resident of nalgonda came with
Cheif complaints:
Pain abdomen since 4 days.
History of presenting illness:
Pt was apparently asymptomatic 3 months back then he developed abdominal pain which was dragging in character for which he was admitted in near by hospital in nalgonda . He was diagnosed with acute pancreatitis and was treated inadequately and was advised to stop consumption of alcohol.
Since then pt has stopped consuming alcohol and has been experiencing alcohol withdrawal symptoms like getting angry , agitation , irritability , craving to consume alcohol, tremors . Pt had consumed alochol 4 days back due to fight with his wife.
In veiw of this symptoms pt.has been brought to psychiatry OPD for deaddiction. He was referred to medicine OPD in veiw of pain abdomen.
Pain was , insidious in onset , started after consuming of alcohol in epigastrium and left hypochondrium which was relieved on bending forward and lying down , aggregated on eating food and standing straight.
No h/o fever , nausea , vomiting.
No h/o chestpain , shortness of breath , constipation.
Past history:
H/o similar complaint in past 3 months back.
No other co morbid conditions
No h/o previous medical surgical history.
Family history :
Not significant
Personal history
Diet : mixed
Appetite : normal
Bowel bladder: regular
Sleep: inadequate
General examination:
Pt was concious coherent and cooperative
Thin built and moderately nourished
Pallor - present
No icterus,cyanosis ,
clubbing,lymphadenopathy, edema
Vitals at the Time of admission
Temperature- afebrile
Pulse rate- 94bpm
Blood pressure-120/80mmHg
Respiratory rate- 16cpm
Systemic examination:
Abdominal examination:
Inspection:
Shape of the abdomen- flat.
Umbilicus is central.
No visible scars,pulsations, peristalsis, engorged veins.
Palpation:
All the inspectory findings are confirmed.
Tenderness present over the epigastrium and left hypochondrium region
Liver palpable 2cms below costal margin
Liver span: 11.5cm ( normal)
Spleen : not palpable
Kidney : not palpable
Percussion:
No free fluid
Ascultation:
Bowel sounds heard .
Other systems:
Respiratory:
b/l air entry present , no added breath sound
CVS :
S1 S2 heard , no added murmurs
CNS :
Higher function intact
No motory and sensory deficit.
Cranial nerves normal .
Investigations:
USG abdomen
Serum amylase : increased to more than three times
Serum lipase.
Diagnosis:
Pseudocyst of pancreas secondary to unresolved acute pancreatitis.
Treatment:
Nil per oral
IV fluids Ringer lactate ,Normal saline 100 ml per hour
Inj. Tramadol100mg in 100ml NS IV BD
Inj.pantop 40 mg IV OD
Inj. Optineurin 1 ampoule in 100ml NS IV OD
Psychiatry medication
Tab . Lorazepam 2mg BD
Tab . Benzothiamine100mg OD.
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