GENERAL MEDICINE CASE PRESENTATION

 Name: A Sanvith

Roll no: 09

INTRODUCTION:

A 70 yr old male agriculture by occupation was brought to causality in an unconscious state since yesterday.

CHIEF COMPLAINT: 

Fever since 3 days 

Abdominal pain since 3 days

HISTORY OF PRESENT ILLNESS:

* Patient was apparently asymptomatic 1 week back after which he started Binge drinking for 2 days.


*He developed Fever that last for 3 days and developed Abdominal pain Burning type both for which he was treated by local Doctor.


* After that he developed weakness which is gradual in onset and was unable to stand for which he was admitted to local hospital where he was diagnosed to have DENGUE FEVER (through NS1 ANTIGEN Positive) and the Platelet Count was 24,000. 


PAST HISTORY:


*Patient is a known case of Chronic Alcoholism since 30 years and increased his intensity since last 3 years. 


*smoking since 20 yrs, average 2 beedi per day


TREATMENT HISTORY:

* No Past history of treatment 


PERSONAL HISTORY:

* He is a chronic alcoholic since 30 years 


* He is smoker since 20 yrs at an average of 2 beedi per day


FAMILY HISTORY:

*No Familial History.


GENERAL EXAMINATION: 

* Patient was in an unconscious state.


*No icterus and pallor.


* No B/l pedal edema 


* No lymphadenopathy 


ON EXAMINATION:

BP: 90/60 mm Hg

PR: 102bpm

GRBS: 34mg/dl

Temperature: 99°F

RR: 36cpm

SpO2: 85% with 4 Liters of O2

Severe Thrombocytopenia with Bleeding Manifestations (Epistaxis).

INVESTIGATIONS:





COMPLETE BLOOD PICTURE



CUE:

COLOUR: Pale Yellow

APPEARANCE: Clear

REACTION: Acidic

SP GRAVITY: 1.010

ALBUMIN: +

SUGAR: Nil

BILE SALTS: Nil 

BILE PIGMENTS: Nil

PUS CELLS: 4-6

EPITHELIAL CELLS: 2-4

RED BLOOD CELLS: Nil

CRYSTALS: Nil

CASTS: Nil

AMORPHOUS DEPOSITS: Absent

OTHERS: Nil

APTT :

APTT TEST: 32 sec

PROTHROMBIN TIME: 

# INR: 1.1

# BLEEDING TIME: 2 min

# CLOTING TIME: 4 min 30 sec

BLOOD SUGAR RANDOM


SEROLOGY 

HIV 1/2 RAPID TEST



HBsAg-RAPID


ANTI HCV ANTIBODIES-RAPID


LIVER FUNCTION TEST (LFT)


RENAL FUNCTION TEST (RFT)



BLOOD GROUPING AND RH TYPE



ABG



CHEST RADIOGRAPHY



PROVISIONAL DIAGNOSIS:

*Dengue shock syndrome

(??Dengue encephalitis) 

*With hepatitis SECONDARY to Dengue? Alcohol??

*With Pre renal AKI

TREATMENT:

1. 25% Dextrose for Hypoglycemia

2. IVF. NS Bolus 1 Litre.

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