1701006196 CASE PRESENTATION
LONG CASE:
Chief complaints :
A 55 year old female who is house maid by occupation came with chief complaints of
- Headache since 20 days
- Fever since 5 days
- Neck stifness since 5 days
History of presenting illness:
Patient was apparently asymptomatic 20 days back then she developed
Headache which was insidious in onset gradually progressive and relieved on medication.Headache was aggregated 5 days back inspite of taking medications. No aggravating and relieving factors
Fever: Insidious onset since 5 days, intermittent fever,not relieved on medications.Fever is not associated with chills and rigors
History of neck stiffness since 5 days
History of one episode of vomiting 3 days back which is non projectile non billious,non blood stained and content is food particles
Patient had no history of cough,dyspnea,burning micturition, loose stools
Past history:
No history of similar complaints in the past
7 yrs back she had history of CVA where both upper and lower limbs are paralysed and took some medication.
she took allopathy medicine for 6 months and she got recovered.
Not a known case of diabetes mellitus, hypertension,asthma, epilepsy, tuberculosis,thyroid
Surgical history: hysterectomy done at 25 years back
Family history:
No similar complaints in the family
Personal history
Diet-mixed
Appetite-normal
Sleep-adequate
Bowel and bladder-regular
No addictions
No allergies
General examination:
patient is examined in a well lit room,with informed consent
Patient is conscious, coherent, coperative. Moderately built moderately nourished.
No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, generalised edema.
Vitals:
Temperature: afebrile
Pulse rate: 78bpm
Resp rate:16cpm
BP:130/80mmhg
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 centrally placed not deviated
• 11- trapezius and 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-. +. +
Meningeal signs -
Neck stiffness- present .
Kernig's sign - positive
Brudzinki sign - positive
Sensory examination-Normal
CARDIOVASCULAR SYSTEM:
S1 S2 Heart sounds – normal
No thrills/murmurs
RESPIRATORY SYSTEM:
Bilateral air entry present
Normal vesicular breath sounds heard,
No abnormal/added sound
ABDOMEN:
Abdomen is soft, non tender,No organomegaly, No ascites.
Investigations
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
Dengue NS1 antigen:
Arterial blood gas analysis:
PH : 7.4
PCo2 : 29.1
PO2 : 88.4
HCO3 : 18
Fasting blood sugar: 168 mg/dl
Complete urine examination:
Albumin : positive
Sugar : nil
Pus cells : 6-8
Epithelial cells : 3-4
RBC and casts : nil
Renal function test :
AST : 69 IU/L
ALT : 68 IU/L
ALP : 135 IU/L
Total protein : 6.4 gm/dl
Albumin : 4.0 gm/dl
Urea : 38 mg/dl
Creatinine : 1.0 mg/dl
Uric acid : 4.9 mg /dl
Serology : Non reactive
INVESTIGATIONS ON 12 JUNE :
Hemogram :
Hb- 13.1
Tlc-16,400 /mm3
Neutrophils- 82
Leukocytes -9
Eosinophil -1
Monocyte -8
Platelet count -1.81lakh/mm3
Arterial blood gas analysis :
PH - 7.44
PCO2 - 28
PO2 - 49.3
HCO3-18.7
O2 sat - 85.1
MRI:
2D ECHO
CSF ANALYSIS:
Sugar : 81
Protein : 12.6
X ray neck:
PROVISIONAL DIAGNOSIS:
Dengue fever with meningoencephalitis
TREATMENT
Intravenous fluids NS and RL
Injection ceftriaxone 2 gm / ml BD
Injection dexamethasone 6 mg intravenous TID
Injection vancomycin 1 gm intravenous sos
Injection paracetamol 1 gm intravenous SOS
Tab paracetamol 650 mg TID
Tab ecosporin 7 mg per oral OD
Tab cremaffin 30 peroral
Tab metformin 500 mg per oral
---------------------------------------------------------------------------------------------------------------
SHORT CASE:
Chief complaints:
A 60 year old female labourer by occupation came with chief complaints of loose stools since 15 days, vomitings since 10 days.
History of presenting illness:
Patient was apparently asymptomatic 15 days back then she developed loose stools which was 8-10 episodes initially and since 4 days decreased to 4-5 episodes per day associated with abdominal pain in upper quadrant colicky in nature non radiating
Vomitings was of 2 episodes previously non bilious non.
Past history:
No history of similar complaints in past
No history of diabetis mellitus, hypertension, asthma, Tuberculosis,CAD.
Personal history::
Diet :mixed
Appetite:normal
Sleep:Adequate
Bowel and bladder: normal
Addictions: occasionally toddy
Treatment history:: insignificant
Surgical history: hysterectomy done 10 yrs back
General examination:
On taking prior consent patient was examined in a well lit room and patient is moderately built and moderately nourished
Patient was conscious coherent cooperative
Well oriented to time place person
Moderately nourished and built
No pallor,icterus,cyanosis, clubbing,lymphadenopathy,edema
Temperature: afebrile
Pulse:82bpm
Respiratory rate:16cpm
Bp:110/80mmof Hg
Systemic examination:
Per abdomen:
Inspection.
Shape of abdomen-scaphoid
Umbilicus-inverted,central located
No sinuses or scars on abdomen
Palpation:
No rise in temperature
Tenderness present over upper quadrant epigastric
No palpable mass
No free fluid
Liver palpable
Spleen not palpable
Percussion:
Dull note on right upper quadrant
No fluid thrill
No shifting dullness
Auscultation:
Bowel sound heard
Respiratory system:
B/L symmetrical elliptical
Trachea central
No sinuses ,scars
Tactile vocal fermitus-equal normal on both sides
Normal vesicular breath sounds heard
Cardio vascular system::
S1S2 heard
No murmurs
Central nervous system:
Speech normal
Cranial nerves normal
Sensory and motor system: intact
Reflexes.normal
Investigations:
Complete blood picture:
Hemoglobin:12.2gm/dl
Total leucocyte count:5500cels/mm3
Neutrophils:70 %
Lymphocytes:20%
Monocytes:04%
Eosinophils:06%
Basophils:0
Platelet count:2L/mm3
Random blood sugar:102mg/dl
Blood urea 42mg/dl
Serum electrolytes:
Na+=137
K+=2.5
Cl-=102
Serum creatinine-1.2mg/dl
Liver function tests:
Total bilirubin:0.91 mg/dl
Direct bilirubin:0.18 mg/dl
AST:41IU/L
ALT:43IU/L
ALP:154IU/L
Total protiens:7gm/dl
Albumin:3.8gm/dl
Smear: normocytic normochromic
HIV RAPID TEST : POSITIVE
Provisional diagnosis:
Gastroenteritis
Treatment:
Iv Fluids
Inj.zofer
Tab.sporolac
Cap radotril
Inj.pan 40
Inj.kcl 1amp in 500ml NS
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