GENERAL MED CASE PRESENTATION

 

 GENERAL MEDICINE CASE PRESENTATION 

A 45 yr old female agriculture by occupation was brought to the casualty.

CHIEF COMPLAINT: 

  • Abdominal pain 
  • Vomiting
  • Fever
  • Burning micturition
  • Cough
  • SOB

HISTORY OF PRESENT ILLNESS:-

* Patient was asymptomatic before 3 days after which she developed abdominal pain ,vomiting ,fever associated with cough ,Burning micturation for the past 3 days.After which she developed SOB ( grade 2-3), pyelonephritis  and  came to casualty in our Hospital.

PAST HISTORY:-

k/c/o HTN since 1 yr.
NOT k/c/o Diabetes,TB

PERSONAL HISTORY:-

* Alcohol intake occasionally.
*Bowel and Bladder movements are Normal.

FAMILY HISTORY:-

*No Familial History.

GENERAL EXAMINATION:-


*No icterus and pallor.

*Pedal edema is present.

* No lymphadenopathy 

ON EXAMINATION:-

BP: 100/70 mm Hg
PR: 86bpm
Temperature: 98.6 F
RR: 18cpm
SpO2: 92 %


INVESTIGATIONS:-


CBP:-






Serum Electrolytes(Na,K,Cl):-


Blood Urea:-


Blood Sugar-Random:-





  LFT:-





Serum Creatinine:-





PROVISIONAL DIAGNOSIS:-

Dengue  Thrombocytopenia 
               
             ?  (R) Pyelonephritis 


TREATMENT:-

*I.V fluids @150ml/hr.
*Inj. PAN 40 mg IV/BD.
*Inj. ZOFER 4 mg IV/TID.
*Inj. TRAMADOL 1amp in 100 ml NS IV/BD.
*Tab. DOLO 650 mg TID.
*Inj. CIPROFLOXACIN 500 mg IV/BD.
*Strict I/O charting.
*BP/PR/Temp/SPO2 monitoring.
*W/F Bleeding manifestations.
*Tab. SPORLAC-DS TID.


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