SHRUTHI ARUKONDA 02

 GENERAL MEDICINE. 


9 June,2022.  

Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

- Shruthi Arukonda 02 
-Ashish 12 
-Hari Krishna 01
        
             CASE REPORT 
 
A 52 year old male with Chief complaints of fever, neck pain, and tightness in abdomen.  

CHEIF COMPLAINTS: 
Patient came to casualty with chief complaints of fever since 4 days and neck pain 
H/o decreased appetite since 3 days. 
H/o tightness of abdomen since 3 days.  

HISTORY OF PAST ILLNESS: 
N/k/c/o of HTN, DM, TB, CAD, Epilepsy.  

TREATMENT HISTORY: 
Nothing significant.  

PERSONAL HISTORY: 
Appetite : decreased 
Alcohol : occasionally.  (Toddy) 
Smoking : no 

FAMILY HISTORY: 
Nothing significant.  

PHYSICAL EXAMINATION: 

GENERAL EXAMINATION: 
No pallor , cyanosis, lymphadenopathy, malnutrition, 

VITALS: 
Temp: a febrile 
Pulse rate: 84/min 
Respiration: 22cpm/min 
BP: 110/70 mmhg
Spo2: 98% 

SYSTEMIC EXAMINATION : 

CVS: 
S1 and S2 normal.  

RESP:  
Dyspnoea: no 
Wheeze:no 
Position of trachea : central 
Breath sounds: vesicular 

ABDOMEN:

Shape: scaphoid 
Tenderness: no 
Free fluid: no 
Bruits: yes
Liver : not palpable.  
Spleen: not palpable. 
Bowel sounds : yes 

CNS: 
Level of conscience: conscious 
Speech : normal 
Neck stiffness : no 

INVESTIGATIONS: 

CBP: 
Hb%- 14.9 Gm/dl 
TLC- 10,500cells/cu mm 
Neutrophils-43
Lymphocytes- 48
Eosinophils- 01
RBC- 5.02 cells/mcl

Blood urea: 59 mg/dl

Serum creatinine : 1.6 mg/dl 

SERUM ELECTROLYTES: 
Sodium : 141 MEq/L 
Potassium :3.9 MEq/L 
Chloride : 103 MEq/L 

LFT: 
TB-1.27 
SGOT- 60 
SGPT-47
ALP-127
TP- 5.9


Albumin - 3.5
A/G Ratio- 1.48 

CUE: clear 
Albumin - ++
Pis cells -4.6 
Epithelial cells : 2-3 

USG:  



ECG: 


PROVISIONAL DIAGNOSIS: 
Viral pyrexia with decreased thrombocytopenia on evaluation.

TREATMENT: 

1. I.V- NS: 100ml/hr
2. I.V- RL: 100ml/hr 
3.inj.PAN 40mg/I.v/O.D
4.inj.zofer 4mg
5. Vitals monitoring 4th hourly 
6.I/o chart monitoring.  
































































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