GM Case 02
General Medicine Case 02
Systemic Examination:-
On 18/08/2021
PROTHROMBIN TIME / PT
DENGUE NS1
Blood Urea
Serum Electrolytes
Liver Function Test
Stool For Occult Blood
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Date of admission:- 16/08/2021
A 17 year old male who is a student , lives in Hyderabad admitted to OPD with complaints of fever, headache and tiredness since 3 days , stomach ache and loose stools since 2 days , vomiting and nausea since yesterday.
History of Present illness:-
-The patient was apparently asymptomatic 4 days ago. The patient developed low grade intermittent fever since past 3 days. And also headache and generalised weakness since 3 days.
-The patient complaints about decreased appetite since 3 days.
-He does have abdomen pain past 2 days .
-He also had 2 episodes of loose stools which was continued for 2 days. And also the stools were watery in consistency , yellowish, non blood tinged.
-He also had 1 episode of vomiting which is non projectile , non bilious.
- He feels nausea since yesterday.
- He apparently visited other hospital yesterday morning and was told to have a platelet count of 20,000.( Thrombocytopenia)
- The Patient shows Petechiae on his hands.
Past History:-
- Patient had typoid fever one and half year ago.
- No history of diabetes, no hypertension.
- No history of T.B , no asthma , no epilepsy, no allergies.
-No history of Chest pain or breathlessness.
Personal history:-
Sleep is not adequate.
Appetite is decreased.
No addictions.
Mixed diet.
Bladder and bowel movements are normal.
No drug use.
No allergies.
Family History:-
No family members has similar complaints.
No family members have allergies.
Treatment History:-
No treatment is taken till now.
General Examination:-
Patient was conscious and cooperative.
Patient shows generalised weakness.
No Pallor , no cyanosis, no icterus, no generalised lymphadenopathy .
Mild ascites. Mild dehydration.
Patient show red spots on hands and legs.
Vitals:-
Temperature-- 99°F
Respiration rate-- 12 breath per min
Pulse rate --94 bpm
Blood pressure-- 120/90 mm Hg supine
100/70 mm Hg standing
SpO2 -- 90%
GRBS-- 104 mg/dl
CVS --- no thrills
Cardiac sounds s1, s2
No cardic murmurs
Respiratory system-- no Dyspnoea
No wheezing
Abdomen--- shape scaphoid
No tenderness
No palpable mass
Free fluid present
Liver-- not palpable
Spleen-- not palpable
CNS--- conscious
Normal speech
Provisional diagnosis:-
Viral pyrexia
Investigations:-
Hemogram
On 17/08/2021
On 18/08/2021
APIT
ECG
Fever Chart
Final diagnosis:-
Dengue fever
Treatment:-
IVF 150 ml/ HR
INJ PANTOP 40 mg IV/OD
INJ ZOPER 4 mg IV /TID
INJ NEOMOL 10g ml IV/ 80S
TAB PCM 650 mg PO/TID
TAB VITAMIN C PO/ODX
PLENTY OF ORAL FULIDS
Questions:-
What is the mechanism behind abdominal pain in dengue??
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