1701006146 prefinal case
26 YR OLD MALE WITH FEVER SINCE I WEEK, VOMITINGS, LOOSE STOOLS SINCE 3 DAYS
Cheif complaints
c/o generalised weakness and headache since 1 week
c/o vomitings since 3 days
c/o loose stools since 3 days
History of presenting illness:
Patient was apparently alright 1week ago then he developed fever which is high grade, intermittent, associated with chills and rigor.
He was in Orissa while he developed fever then he returned to his home 2 days later.
He also had headache and generalised weakness since 1 week
He developed vomitings since 3 days, 5 episodes, with food as content, non bilious, non projectile, not blood stained
Loose stools since 3 days, 3 episodes/day, watery, green coloured, not blood stained.
He went to a doctor outside but the symptoms didnot subside, then he came here on 7/6/23
H/o hematuria and green coloured stools since 3 days
There is H/o taking papaya leaf juice for 3days in the morning before food
Past history
No H/o similar complaints in the past
Not a k/c/o DM, HTN, Thyroid disorders, epilepsy, asthma.
Personal history
He has normal appetite, takes mixed diet, increased bowel movements, sleep is adequate.
He takes alcohol 2 quarters from 6 years
On examination:
Patient is conscious, coherent and cooperative
No pallor, clubbing, cyanosis, lymphadenopathy, pedal edema
Vitals
Temp- 99.5F
PR- 86 bpm
RR- 20 cpm
BP- 100/70mmHg
Spo2 - 99% on RA
RS-B/L air entry present
NVBS
CVS- S1S2 present, no murmurs heard
PA- Soft,non tender
CNS: NAD
Investigations
On 7/6/23
Hb: 14.9gm/dl
TLC: 900cells/cumm
RBC: 4.79 millions/cumm
PLATELETS: 50000 /cumm
Blood urea:52 mg/dl
Serum creatinine: 1.4 mg/dl
Serum Na+:137 mEq/L
Serum K+:4.3mEq/L
Serum Chloride:99 mEq/L
Bleeding time: 2min 30sec
Clotting time: 5min 00sec
PT: 20sec
INR: 1.4
APTT:41 sec
Stool for occult blood: Positive
CUE
Albumin:+
Pus cells: 3-4/HPF
RBC: plenty
On 8/6/23
Hb: 13.3gm/dl
TLC: 900cells/cumm
Platelets: 50000 /cumm
RBC: 4.17million/cumm
Peripheral smear
RBC: Normocytic normochromic
WBC: counts decreased on smear
Platelet: counts decreased on smear
On 9/6/23
Hb: 12 gm/dl
TLC: 1300cells/cumm
RBC:3.78million/cumm
Platelets: 90,000/cumm
PCV: 35.4vol%
Serum creatinine:0.9mg/dl
Serum Na+ :139mEq/L
Serum K+: 4 mEq/L
Serum Chloride: 101mEq/L
APTT:43 Sec
PT: 22Sec
INR:1.62
Total Bilirubin: 4.93 mg/dl
Direct bilirubin: 3.46mg/dl
SGOT: 50 IU/L
SGPT: 18IU/L
Total proteins 5.0gm/dl
Albumin: 2.44gm/dl
A/G ratio: 0.95
On 10/6/23
Total Bilirubin: 2.37 mg/dl
Direct bilirubin: 1.99 mg/dl
SGOT: 79 IU/L
SGPT: 25 IU/L
Total proteins 4.5 gm/dl
Albumin: 1.69 gm/dl
A/G ratio: 0.58
Hb: 11.5 gm/dl
TLC: 1100 cells/cumm
RBC:3.63 million/cumm
Platelets: 62,000/cumm
PCV: 34.2 vol%
On 11/6/23
Total Bilirubin: 1.57 mg/dl
Direct bilirubin: 0.65 mg/dl
SGOT: 64 IU/L
SGPT: 30 IU/L
Total proteins 4.6 gm/dl
Albumin: 2.21 gm/dl
A/G ratio: 0.92
Hb: 11.3 gm/dl
TLC: 2000 cells/cumm
RBC: 3.58 million/cumm
Platelets: 70,000/cumm
PCV: 34 vol%
On 12/6/23
Hb: 11.6 gm/dl
TLC: 2400 cells/cumm
RBC: 3.66 million/cumm
Platelets: 80000/cumm
PCV: 35.2 vol%
Total Bilirubin: 1.17 mg/dl
Direct bilirubin: 0.23 mg/dl
SGOT: 62 IU/L
SGPT: 49 IU/L
Total proteins 6.2 gm/dl
Albumin: 3.3 gm/dl
A/G ratio: 1.74
Serum electrolytes
Serum Na+ :140mEq/L
Serum K+: 4mEq/L
Serum Chloride: 100mEq/L
Pyrexia with bicytopenia
Treatment:
1.IV FLUIDS NS, DNS, RL@ 125 ml/hr
2.Tab.DOLO 650mg PO/TID
3.Inj.NEOMOL 1gm IV/SOS (if temp>102F)
4.Monitor vitals
