CBBLE UDHC SIMILAR CASES
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 AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
33 year old female came with the chief complaints of :
Arthralgia since 2 months
Fever since 5 days
Vomitings and loose stools since 4 days
Abscess over the right thigh (?ruptured) since 5 days .
HOPI :
Patient was apparently asymptomatic 2 months ago then she developed fever which is of low grade associated with polyarthralgia lasted for 15 days for which she used Tab . Paracetamol , Tab.Diclofenac after which the patient still didn't get any relief
There's no effect of her symptoms on her daily activities and her occupation.
The patient took COVID vaccine
H/o small and large joint pains with swelling around the joints
Due to the persistence of fever and polyarthralgia the patient visited rheumatologist in the month of October (RF -Normal ,HB - 9 g/dl , ESR -110 )
There the patient was advised :
1.Tab .HCQ 200 mg OD for 2 weeks (8pm)
2.Tab.Prednisolone 20 mg OD for 2 weeks (8am)
3.Tab.Azathioprine 50 mg OD in the morning for 2 weeks
After using these medicines her symptoms got subsided
Today patient has come to our hospital with fever which is of high grade associated with chills and rigors , vomitings - non bilious ,non projectile , food and water as the content , stools - watery in consistency ,large volume mucous , no blood in stools
No h/o Malena ,hematuria
Past history :
Not a k/c/o diabetes mellitus , hypertension, asthma ,cad , tuberculosis
Past surgical history :
Tubectomy done 10 years ago
Personal history :
Diet -mixed
Appetite - decreased since 2 months
Bowel habits - regular
Bladder habits - urgency present
Sleep - adequate
No addictions
Family history :
Patient's mother is a known case of diabetes and hypertension since 10 years
Obstetric history :
Age of marriage - 18
P2L2
General examination :
Patient is conscious, coherent,cooperative ,thin built and poorly nourished
Mild pallor present
No cyanosis , icterus , clubbing,lymphadenopathy , edema
Mild dehydration present
Vitals :
Pulse rate - 88 bpm
Temperature- 100°F
RR - 12 cpm
BP - 80/50 mmHg
Systemic examination :
CVS : S1 S2 + , no added murmurs
RS :BAE + ,NVBS heard
CNS : no focal neurological deficits
P/A :soft , non tender
No organomegaly
No distension
Bowel sounds heard
Local examination of the abscess :
1 x 1 cm wound present over the anterior aspect of left thigh with surrounding erythema .
Local rise of temperature +
Tenderness +
No pus discharge
(Diagnosis given by the surgery dept for the abscess - Ruptured sebaceous cyst )
Advice given for the abscess :
1.Tab CHYMEROL forte -TID
2.Tab Hifenac -P PO /BD
3.Tab Vit -C PO /OD
4.Regular dressings
Investigations sent on the day patient got admitted :
1.ECG
2.USG abdomen - no sonological abnormality detected
3.RFT : urea - 20 mg/dl , creatinine - 0.7 mg/dl ,Na+ - 146 meq/L , K+ - 4.2 meq/L , Cl- 105 meq/L
4.LFT : TB - 1.21 , DB - 0.26 , AST - 26 , ALT - 10 , ALP - 95 , TP - 5.9 , Albumin - 3.2 , A/G ratio - 1.22
5.Hemogram : HB - 8.5 g/dl , TLC - 1,300 , N/L/E/M - 61/27/2/10 , PLt - 1.19 , RBC - 2.90
PCV - 24.1 , MCV - 83.1 , MCH - 29.3
6.ESR - 85 mm
7.CUE : Sugar , albumin - nil , pus cells - 3 to 4
E.cells - 2 to 3
8.Malarial parasite - negative
9.Chest x-ray
Previous investigations of the patient :
HB - 9.5 g/dl
TLC - 2,900
PCV - 28.1
PLt - 1.89
K+ - 2.8
HB - 9 g/dl
TLC - 4,900
PLt - 2.69
R factor - normal
CRP - 9
ESR - 10
Alb - 3.9
TSH - 7.16 micro IU/ml
USG - free fluid in the pelvis
Provisional diagnosis :
Acute Gastroenteritis (infective cause ) with ruptured sebaceous cyst with polyarthralgia under evaluation.
Treatment given :
1.IVF - NS , RL @ 100 ml/hr
2.Inj Optinneuron 1 amp in 100 ml NS IV/OD
3.Inj Neomol 1 gm IV SOS (if temp >=101 degree Fahrenheit)
4.Inj Pantop 40 mg IV OD
5.Inj Zofer 4 mg IV TID
6.Inj Ceftriaxone 1 gm IV BD
7.Tab Sporolac -DS PO TID
8.Tab Dolo 650 mg PO TID
9. Tab Baclofen 12.5 mg PO SOS ( if hiccups persist )
10.ORS sachets in 1 litre of water - 100 ml /stool.
11.Tab Redotil 100 mg PO /BD
Diagnosis : Acute Gastroenteritis (infective cause ) with ruptured sebaceous cyst with polyarthralgia under evaluation with pancytopenia
Investigations :
1.Reticulocyte count - 0.5
2.Absolute reticulocyte count - 0.3
3.RI - 0.1 (Hypoproliferative marrow )
4.T3 - 0.86
5.T4 - 10.04
6.TSH - 7.38
7.Spot protein creatinine ratio - 0.75
SOAP NOTES
AMC bed 1
S- No fever spikes
No nausea/vomitings
O - pt is c/c/c
Afebrile
PR-86 bpm
BP - 110/70 mmHg
RR - 20 cpm
SPO2 - 96 % at RA
CVS - S1 S2 +
CNS - NAD
RS - BAE +
P/A - soft , non tender
I/O - 3200/1950 ml
GRBS - 89 mg/dl
A - Acute gastroenteritis (Resolved ) with ruptured sebaceous cyst with pancytopenia under evaluation
P- 1.IVF - NS and RL @ 75 ml/hr
2.Plenty of oral fluids
3.Inj pantop 40 mg IV OD
4.inj Zofer 4 mg IV SOS
5.inj Ceftriaxone 1 gm IV BD
6.tab dolo 650 mg po sos
7.tab Sporolac -DS po sos
8.thrombophore ointment for l/a
9.I/O and temperature charting
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