fever proj dengue 50/m 202408699

 Diagnosis

VIRAL PYREXIA WITH THROMBOCYTOPENIA

ACUTE KIDNEY INJURY

? URINARY TRACT INFECTION

Case History and Clinical Findings

A 50 YR OLD MALE CAME TO CASUALTY WITH C/O FEVER SINCE 4 DAYS

COUGH AND COLD SINCE 4 DAYS

C/O BODY PAINS HEADACHE ABDOMINAL PAIN VOMITINGS SINCE 4 DAYS

HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC SINCE 4 DAYS AGO THEN HE DEVELOPED FEVER INTERMITTENT LOW GRADE A/W CHILLS AND RIGORS NO DIURNAL VARIATION NO MYALGIA RETROORBITAL PAIN

GENERALISED WEAKNESS +

H/O VOMITING 1 EPISODE FOOD AS CONTENT NON PROJECTILE NON BILIOUSNON FOUL SMELLING

H/O FRONTAL HEADACHE INTERMITTENT

H/O ABDOMINAL PAIN AND REBOUND TENDERNESS+

H/O COUGH COLD SPUTUM + SCANTY WHITISH NON BLOOD STAINED NON FOUL SMELLING

H/O BODY PAINS

PAST HISTORY

N/K/C/O HTN, DM, TB, ASTHMA, EPILEPSY, THYROID DISORDERS, CAD CVA

PERSONAL HISTORY:

OCCUPATION-FARMER


DIET-NON VEGETARIAN

APPETITE-LOST

SLEEP-ADEQUATE

BOWEL MOVEMENTS-REGULAR

ADDICTIONS- ALCOHOLIC STOPPED 5 YEARS AGO

GENERAL EXAMINATION:

AFEBRILE 98.2 F

BP:120/80 MMHG

PR:92 BPM

RR:17 CPM

SPO2: 98% @RA

SYSTEMIC EXAMINATION

CVS:S1 S2 HEARD

NO MURMURS

CNS: NO FOCAL NEUROLOGICAL DEFICITS

P/A: DISTENTED, SHIFTING DULLNESS + REBOUND TENDERNESS +

RS:BAE+ ,NORMAL VESICULAR BREATH SOUNDS PRESENT.

GENERAL SURGERY REFERRAL WAS DONE ON 22/2/24

AND WAS ADVISED

TAB PAN 40MG PO OD BBF

TAB HIFENAC P PO BD

STARTED ON CEFOPERAZONE SALBUTAMOL

TAB MVT PO OD

TAB VIT C PO OD

NEPHROLOGIST OPINION IVO RAISED SR CREATININE

Investigation

LIVER FUNCTION TEST (LFT) 22-02-2024 Total Bilurubin 2.24 mg/dlDirect Bilurubin 1.46 mg/dlSGOT(AST) 57 IU/LSGPT(ALT) 42 IU/LALKALINE PHOSPHATASE 776 IU/LTOTAL PROTEINS 5.5 gm/dlALBUMIN 2.6 gm/dlA/G RATIO 0.90


COMPLETE URINE EXAMINATION (CUE) 22-02-2024 COLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 4-5EPITHELIAL CELLS 3-4RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilWIDAL TEST 22-02-2024 S.typhi 'O' Antibodies No Agglutination seenS.typhi 'H' Antibodies No Agglutination seenS.PARATYPHI 'AH' ANTIBODY No Agglutination seenS.PARATYPHI 'BH' ANTIBODY No Agglutination seen

Anti HCV Antibodies - RAPID 22-02-2024 Non ReactiveHBsAg-RAPID 22-02-2024 Negative

SERUM ELECTROLYTES (Na, K, C l) 22-02-2024 SODIUM 135 mEq/LPOTASSIUM 5.7 mEq/LCHLORIDE 106 mEq/LSERUM CREATININE 22-02-2024 7.1 mg/dl

BLOOD UREA 22-02-2024 244 mg/dlABG 23-02-2024PH 7.44PCO2 27.2PO2 112HCO3 18.5St.HCO3 21.5BEB -3.5BEecf -4.8TCO2 35.5O2 Sat 95.3O2 Count 20.6

BLOOD UREA 23-02-2024 281 mg/dlSERUM CREATININE 23-02-2024 6.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 23-02-2024 SODIUM 134 mEq/LPOTASSIUM 5.2 mEq/LCHLORIDE 107 mEq/LBLOOD UREA 23-02-2024 271 mg/dl

SERUM CREATININE 23-02-2024 7.0 mg/dlSERUM ELECTROLYTES (Na, K, C l) 23-02-2024 SODIUM 134 mEq/LPOTASSIUM 5.3 mEq/LCHLORIDE 105 mEq/L

ABG 24-02-2024 PH 7.27PCO2 18.0PO2 128HCO3 8.2St.HCO3 11.7BEB -17.1BEecf -17.5TCO2 17.2O2 Sat 96.5O2 Count 15.3

HEMOGRAM ON 8/2/24

HB- 11.6 GM/DL

TLC- 12800 CELLS/CUMM

PLT 3.05 LAKHS/CUMM

PCV 32.9

RBC 4.06 MILLIONS/CUMM

USG ABDOMEN

MILD HEPATOMEGALY

ASCITES

2D ECHO

MODERATE TR+ WITH PAH

MILD AR+ MILD MR+

SCLEROTIC AV NO AS/MS

AML MILD CALCIFIED

EF=64% RVSP 55MMHG

GOOD LV SYSTOLIC FUNCTION


DIASTTOLIC DYSFUNCTION +

IVC SIZE 1.08 CM COLLAPSING

Treatment Given(Enter only Generic Name)

NEB WITH SALBUTAMOL 6TH HRLY

INJ ZOFER 4MG IV SOS

IVF NS AT 100ML/HR

INJ MAGNEX FORTE 1.5GM IV BD

INJ LASIX 40MG IV TID IF SBP >110MMHG

INJ NEOMOL 1GM IV SOS

INJ HAI 8U IN 100ML 25%D OVER 30-40MINS IV STAT

INJ CEFOPERAZONE WITH SULBACTAM 1.5GM IV BD

TAB PAN 40MG PO OD BBF

TAB HIFENAC P PO BD

TAB MVT PO OD

TAB VIT C PO OD

PROTEN POWDER 2 SCOOPS IN 1 GLAS OF MILK

WATCH FOR BLEEDING MANIFESTATIONS

STRICT I/O CHARTING

MONITOR VITALS 2ND HRLY

Advice at Discharge

LAMA NOTES

PATIENT AND PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT THE PATIENT CONDITION THAT IS VIRAL PYREXIA WITH THROMBOCYTOPENIA WITH MODS ?AKI/?UTI, S/P LAPAROTOMY FOR INTESTINAL OBSTRUCTION, THE RISK AND COMPLICATIONS ASSOCIATED WITH IT, THE NEED FOR HEMODIALYSIS IN THEIR OWN UNDERSTANDABLE LANGUAGE.

BUT THEY ARE NOT WILLING FOR FURTHER STAY IN THE HOSPITAL FOR HEMODIALYSIS DUE TO PERSONAL REASONS AND WANT TO LEAVE AGAINST MEDICAL ADVICE DESPITE EXPLAINING THE PLAN OF MANAGEMENT AT OUR CENTER.

DOCTORS, HOSPITAL STAFF AND AMINISTRATION ARE NOT RESPONSIBLE FOR ANY UNTOWARD EVENTS OUTSIDE THE HOSPITAL.




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