general medicine postings case 3

I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan

Ch.preethi

Admission number:176050
27 year old men came to causality on 24/01/23 with 
C/O FEVER SINCE 1 WEEK
HOPI:
PATIENT WAS APPARENTLY NORMAL 1 WEEK BACK.HE THEN HAD FEVER WHICH WAS HIGH GRADE, INTERMITTENT WITH EVENING RISE OF TEMPERATURE AND NO CHILLS AND RIGORS AND IS RELIEVED BY MEDICATION.FEVER RELIEVED NOW.
H/O COLD AND COUGH WITH EXPECTORATION-WHITE MUCOID SPUTUM,NOT BLOOD TINGED.
H/O PAIN ABDOMEN TO RIGHT SIDE OF ABDOMEN.
H/O VOMITINGS 3 DAYS BACK-4 EPISODES AND RELIEVED BY MEDICATION.
H/O PASSING BLACK STOOLS SINCE YESTERDAY.

HISTORY OF PAST ILLNESS:
NO SIMILAR COMPLAINTS IN THE PAST
NOT A K/C/O DM/HTN/TB/ASTHMA/EPILESPY/CVA/CAD.
PERSONAL HISTORY:
DIET:MIXED
APPETITE:NORMAL
BOWEL AND BLADDER:REGULAR
SLEEP: ADEQUATE

GENERAL PHYSICAL EXAMINATION:
NOPALLOR,ICTERUS,CYNOSIS,CLUBBING,LYMPHADENOPATHY.
VITALS:
TEMP:98.5F
PR:80/MIN
RR:16/MIN
BP:130/70 MMHG
GRBS:302 MG/DL
SYSTEMIC EXAMINATION:
CVS: S1 S2 HEARD,NO MURMURS
RS: B/L AIR ENTRY PRESENT.
CNS:HIGHER MENTAL FUNCTIONS INTACT.

 DIAGNOSIS:
DENGUE NSI POSITIVE WITH THROMBOCYTOPENIA (RESOLVED) WITH ACUTE CHOLECYSTITIS(RESOLVING).

INVESTIGATIONS:
ON 24/01/23
SEROLOGY:NEGATIVE.
DENGUE: NS1 POSITIVE.
HB: 16.1-15.5
TLC: 2100- 3100
RBC:5.63
PC:15000-18000
 NCNC WITH LEUCOCYTOPENIA AND THROMBOCYTOPENIA.
S.UREA:20
TB-0.9
DB-0.16
SGOT-131
SGPT-55
ALP-214
TP-5-6
ALBUMIN-3.3
A/G-1.48.

27/01/23
PLT-50000
TLC-2800
HB-13.1G/DL.

28/01/23
HB-12.9
TLC-3000
PC-68000
S.AMYLASE-145
S.LIPASE-84
NEUTROPHILS-30
LYMPHOCYTES-50
RBC-4.49

USG ON 25/01/23
GB WALL EDEMA 
MODERATE ASCITIS
ACUTE CHOLECISTITIS
HYPER ECHOIC FOCI NOTED IN GB-LIKELY POLYP OR ADHERENT CALICULUS.

             ECG ON 25/01/23


P
1.TAB.TAXIM 200MG/PO/BD

2.TAB.PANTOPPRAZOLE/40MG/PO/OD.
3.TAB.TECZINE 10MG/PO/HS.
4.TAB.DOLO 650MG/PO/SOS.
5.CALSOFT AF LOTION FOR LA.
6.PLENTY OF ORAL FLUIDS.

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