GENERAL MEDICINE CASE DISCUSSIONS

17 year old female came to casualty with chief complaints of fever, headache, low back ache since yesterday.
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic till yesterday, then developed which is insidious on onset, gradually progressive, not associated with chills and rigor, no diurnal variation, no sweating. 
C/o headache(diffuse type) not associated with nausea/vomiting.
C/o low back ache(diffuse type) not radiating.
No c/o cough, sob. 
PAST HISTORY :
not a k/c/o DM/HTN/TB/Epilepsy.
PERSONAL HISTORY :
appetite-normal
Sleep-adequate
Bowel and bladder-regular
No any addiction 
TREATMENT HISTORY :
No significant treatment history 
FAMILY HISTORY :
NO significant family history. 

GENERAL EXAMINATION :
Patient is conscious coherent and co-operative
Temp:Afebrile
Bp:100/60 mm hg
Pr:93/min
Spo2:100% at RA
GRBS:115 mg/dl
No pallor, icterus,cyanosis clubbing,edema,lymphadenopathy.
SYSTEMIC EXAMINATION :
cvs:S1,S2 heard
RS:NVBS heard
Abdomen:soft,non tender
CNS:NFND
PROVISIONAL DIAGNOSIS :
VIRAL PYREXIA. 

PLAN OF CARE:
1.IVF:NS,RL@75 ml/hr
2.TAB.DOLO 650mg/PO/TID
3.TAB.PANTOP 40mg/PO/OD
4.TAB.ZOFER 4MG/PO/SOS
5.INJ.OPTINEURON 1 amp in 500ml/NS/IV/OD
6.BP/PR/TEMP. charting 4th hrly


Comments

Post a Comment

Popular posts from this blog

GM CASE DISCUSSIONS.

40 year old male came to casualty  with c/o fever, cough with blood tinged sputum(1 episode),red coloured urine associated with B/L loin pain.  HISTORY OF PRESENT ILLNESS : Patient was apparently asymptomatic 1week back then he developed  fever, insidious in onset, no diurnal variation, subsided on taking medication for 2-3 hrs.H/o burning micturition since 2-3 days.H/o passage of red coloured urine after taking medication (?suggested COVID tablets).  H/o cough with blood tinged sputum since yesterday.H/o  B/L loin pain,non radiating.  PAST HISTORY : Not a k/c/o DM/HTN/ASTHMA/EPILEPSY/TB PERSONAL HISTORY : appetite-normal Sleep-adequate Bowel and bladder-burning micturition Addictions-1bidi/day since 30 years.  No significant family and treatment history.  GENERAL EXAMINATION : pt. is c/c/c TEMP:Afebrile BP:110/80 mm Hg PR :78 bpm Nopallor,icterus,cyanosis,clubbing,lymphadenopathy,edema. SYSTEMIC EXAMINATION : CVS:S1,S2 heard RS:BAE +  P/A: soft, non tender CNS: NFND PROVISIONAL DIAGNO
Read more

GENERAL MEDICINE CASE DISCUSSIONS

Image
A 21 year old woman, hailing from Nalgonda, Telangana presented with the cheif complaints of  Vomiting since 4 days Weakness in all her four limbs since 4pm since day  before yesterday  Patient studied till 10th grade at  Nalgonda government school. She was alright until 1 year back, after which she started finding it hard to control her urine, she started wetting her clothes frequently and her mother would always find her bed wet. She was brought to our hospital where in her mother was told that her right kidney was entirely damaged so they had to place a pipe into her left kidney. She had a gross right hydroureteronephrosis and a moderate left hydroureteronephrosis. A left nephrostomy was done for her along with bladder biopsy, she was on the drain for 6 months after which it was removed. Her bladder biopsy revealed granulomatous picture suspicious of TB.  The patient was diagnosed with Genitourinary TB and Thimble bladder. She was started on ATT and  ureterosigmoidostomy was perform
Read more

General medicine case discussions.

Image
70YR OLD WITH ALTERED SENSORIUM 13/9/21 A 70 year old female  Came to casuality with complaints of fever since 10 days and generalized weakness(Patient stopped going to work)-Patient was active and does her regular activities History of present illness:- C/0 fever since 10 days,high grade,intermittent, not associated with chills and rigors Patient went to local rmp and took medication for fever,but still fever was persistent,yesterday evening Patient went to local hospital and one pint of NS was given and sent home,yesterday night pt became drowsy and not responding to commands  so today morning pt visited local Hospital and few investigations were done and referred here for further evaluation  On presentation to casuality, pt was drowsy(Gcs-e3,v1,m4) and had 2 episodes of absence seizures.  Arousable  on deep painful stimulus  No h/oheadache,involuntary movements,head trauma or weakness No h/0 cough,cold, pedal edema, SOB,pain abdomen,loose stools,vomitings Past history: H/o previous
Read more