50 year old man with altered sensorium, pain in abdomen and fever
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A 50 year old male resident of Miryalaguda, farmer by occupation came to the casualty in a stuporous state with complaints of pain in the abdomen since 3 weeks, loss of appetite since 10 days, history of vomitings since 3 days and fever since 3 days.
HISTORY OF PRESENTING ILLNESS -
Patient was apparently asymptomatic 15 days ago, when he developed pain in abdomen in the epigastric region following an episode of alcohol intake the previous night, associated with 3 episodes of vomitings-food particles as content. Fever was insidious in onset and gradually progressive.
PAST HISTORY -
No similar complaints in the past.
Not known case of DM, HTN,CVA,CAD, epilepsy.
He tested positive for COVID-19 on Day 2 of admission.
He was diagnosed with DENGUE (by IgM test) 6 days prior to admission.
PERSONAL HISTORY :
Diet- mixed
Appetite- loss of appetite since 10 days
BOWEL - CONSTIPATION SINCE 3 DAYS
Bladder- regular
ADDICTIONS-
H/O smoking since the past 30-35 years (2-3 bidis per day)
ALCOHOL- Regular intake of alcohol since the past 30-35 years (90-180ml consumption of whiskey )
FAMILY HISTORY: Not significant.
TREATMENT HISTORY: Not Significant
ON EXAMINATION -
Patient is drowsy and not cooperative.
ICTRUS -PRESENT
Pallor, clubbing, cyanosis, lymphadenopathy, edema- absent
VITALS -
TEMPERATURE - 102°F
PULSE RATE - 98BPM
BLOOD PRESSURE - 130/80 MM OF HG
RESPIRATORY RATE - 22
SPO2 - 98% AT ROOM AIR
GRBS:132MG/DL
GCS-E3V2M4
PUPILS:NSRL
SYSTEMIC EXAMINATION -
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM :
BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
P/A - soft, no tenderness
, no organomegaly
CNS:
Pt is DROWSY,NO RESPONSE,
non cooperative
Neck STIFFNESS+
kernig sign+.
Motor system:
Tone - Rt Lt
U/L N N
L/L N N
Investigations:
USG ON DAY 1 of ADMISSION
1.SURFACE IRREGULARITY WITH ALTERED ECHO TEXTURE OF LIVER.
2.GB WALL EDEMA
3.MILD ASCITIS.
LFT:
TB-8.95
DB-3.85
AST-64
ALT-190
ALP-319
TP-4.7
ALB-2.77
A/G-1.44
PT-20
INR-1.4
APTT-38
RFT: UREA-49,CREAT-0.9,URIC ACID-2.8,CA++-7.7,K+-2.9,CL-96,Na-140
CUE-NORMAL
SEROLOGY:NEGATIVE
ABG: suggestive of RESPIRATORY alkalosis may be due to anxiety.
pH-7.51
pCO2-27
pO2:85.5
HCO3:21.2
LACTATE:3.50
Opthamology referral was done.
Findings in left eye:
Lids-discharge at canthus
Conjunctiva- early inflammed nasal pterygium
Mild congestion +
Cornea-clear
Sclera-yellowish discoloration +
PROVISIONAL DIAGNOSIS: ?DENGUE ENCEPHALITIS
TREATMENT:
1.IVF-NS,RL@100ML /HR
2.INJ.MONOCEF 1 GM /IV/BD
3.INJ.ZOFER 4MG/IV/TID
4.INJ.THIAMINE 2 AMP IN 100ML NS/IV/STAT
5.INJ.NEOMOL 1 GM/IV/STAT
6.TAB.PCM 650MG/PO/TID
7.SYP.LACTULOSE 20ML/PO/TID
8.PROCTOLYTIC ENEMA-P/R-TWICE DAILY
9.INJ.DOXYCYCLIN E 100MG/IV/BD
10.INJ.VIT K 10MG IV_OD
11.INJ.PAN 40 MG /IV/BD
Day-1 ICU BED-2
soap notes.
50YEAR/male
S-C/O ALTERED SENSORIUM AND FEVER
O-
O/E:Icterus-present
No pallor/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema
Temp:96.1
PR:75bpm
BP:140/80 mm of hg
RR:24cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:SOFT,NONTENDER
A- ?DENGUE ENCEPHALITIS
P-
1.IVF-NS,RL@100ML /HR
2.INJ.MONOCEF 1 GM /IV/BD
3.INJ.ZOFER 4MG/IV/TID
4.INJ.THIAMINE 2 AMP IN 100ML NS/IV/STAT
5.INJ.NEOMOL 1 GM/IV/STAT
6.TAB.PCM 650MG/PO/TID
7.SYP.LACTULOSE 20ML/PO/TID
8.PROCTOLYTIC ENEMA-P/R-TWICE DAILY
9.INJ.DOXYCYCLIN E 100MG/IV/BD
10.INJ.VIT K 10MG IV_OD
11.INJ.PAN 40 MG /IV/BD
LP DONE.
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