50 year old with viral pyrexia
50 YRS OLD MALE WITH VIRAL PYREXIA & THROMBOCYTOPENIA WITH AKI &PLEOMORPHIC ADENOMA OF RT PAROTID GLAND & OBSTRUCTIVE JAUNDICE
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
Cheif complaints:
A 50 yr old male came to casuality with complaints of fever since 3days and vomitings since 3 days
History of present illness:
Patient was apparently asymptomatic 3 days back then he had intermittent fever which is insidious in onset not associated with cold and cough and relieved with medications and vomitings since 3 days after eating food and food as content, non projectile, nonbilious,motions , burning micturition,dyspnea,headache,darkstools, bleeding from gums
Past history:
k/c/o DM since 6 years on medication metformin 500 mg K/c/o HTN since 3 years not on regular medication and patient does not know the name of medication
Family history : not significant
Daily routine :
He used to wake up at 6:00AM,Completes his needs & Breakfast by 10: Am,Then goes to his work (BARBAR).
Personal history :
Sleep:Adequate
Diet : mixed
Appetite : normal
Bladder &Bowel:regular
H/o alcohol intake daily 90 ml from 10 yrs .
General Examination:
O/E : pt is c/c/c
No pallor , cyanosis , clubbing ,
Icterus ( ), edema upto the ankles
Vitals:
PR: 80 bpm
Bp: supine :110/70 mmhg
Prone: 110/70 mm hg
Spo2 : 97 %
CVS : s1s2
Cns : NAD
RS: BAE
P/A: soft , Bs , NT
On percussion : hepatomegaly
Abdomen: Gall badder oedema
USG OF SWELLING OVER RT MANDIBLE:-
E/o 4.5x3cm solid cystic lesion with solid component showing increased vascularity noted in superficial lobe of right parotid extending into deep lobe.
Enlarged 1b cervical lymph node measuring 9mm along SAD
Investigations& Chest X-ray :
Viral Pyrexia with thrombocytopenia with AKI with pleomorphic adenoma with obstructive jaundice
TREATMENT:-
1) IVF NS , RL @150ml /hr
2)Grbs charting 8 th hrly
3) Temp charting hrly
UPDATE:-
50year /male
S-C/o Fever , c/o vomitings subsided
O/E:No pallor/Cyanosis/Clubbing.
Icterus ( ), edema above the ankles
Enlarged 1b cervical lymph node measuring 9mm along SAD
Temp:98.4f
PR:98bpm
RR:22cpm
BP:supine :130/90mm of hg
Prone : 130/90mm of hg
CVS:S1,S2 heard,no murmurs
RS:BAE ,NVBS heard
P/A:SOFT,NONTENDER,BS , Hepatomegaly ( )
A: Dx-viral pyrexia with thrombocytopenia with AKI with pleomorphic adenoma with obstructive jaundice
Rx: 1) IVF NS , RL @150ml /hr 2)Grbs charting 8 th hrly 3) Temp charting hrly 4) Strict I/o charting |
AMC UPDATE
50year /male
S-C/o Nausea , c/o fever subsided
O-
O/E:No pallor/Cyanosis/Clubbing.
Icterus ( ), edema above the ankles
Enlarged 1b cervical lymph node measuring 9mm along SAD
Temp: 98.4 f
PR:89 bpm
RR:20 cpm
BP:supine :130/80 mm of hg
Standing : 130/80 mm of hg
I/O 2600/1500ml
CVS:S1,S2 heard,no murmurs
RS:BAE ,NVBS heard
P/A:SOFT,NONTENDER,BS , Hepatomegaly ( )
Hb:11.3
Plt count:20000
TLC:10600
Sr creatinine:4.9 mg/dl
Blood urea:101mg/dl
Total Bilirubin :6.30 mg/dl
Direct Bilirubin:4.42 mg/dl
Dx:-viral pyrexia with thrombocytopenia with AKI with pleomorphic adenoma with obstructive jaundice
Rx: 1) IVF NS , RL @150ml /hr 2)Grbs charting 8 th hrly 3) Temp charting hrly 4) Strict I/o charting |
5. Inj Zofer 4mg IV /sos |
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