General medicine Case - By Shravani Reddy

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GENERAL MEDICINE CASE PRESENTATION

●INTRODUCTION 

A 45 yr old male is chronic alcoholic since 20 yrs carpenter by occupation was brought to causality in a state of altered sensorium since 1 day.

•CHIEF COMPLAINTS 

•Difficulty in walking&decreased appetite since 15 days

•Constipation since 5 days

•Fever and pedal edema since 3 days

•Vomiting since 2 days

•HISTORY OF PRESENT ILLNESS

•Patient was apparently asymptomatic 6 months 

Back until he had b/l pedal edema.he has diagnosed with hypothyroidism 

•Patient had difficulty in walking and decreased appetite since then.

•H/o constipation since 5 days.

•Fever - low grade , intermittent , releived with treatment since 3 days.

•B/l pedal edema - pitting , extending upto knees since 3 days.

•Vomiting - non bilious , non projectile , associated with food particles since 2 days.

•Altered sensorium since 1 day.

•Not a k/c/o DM/HTN/Asthma/Epilepsy/CAD/TB

•HISTORY OF PAST ILLNESS 

•1.5 month back he had history of fever,dry cough&weight loss from then

•1 month back he had tingling&numbness in b/l lower limbs till ankle later he diagnosed as peripheral neuropathy,patient had difficulty in walking and decreased appetite since then

•TREATMENT HISTORY 

•He was on T.Thyronorm 25mcg for hypothyroidism 

•PERSONAL HISTORY 

•HE is chronic alcoholic since 20 yrs

•FAMILY HISTORY 

•No familiar history 

•GENERAL EXAMINATION 

•Patient was in altered sensorium 

•Moderately built and moderately nourished

•No Icterus and pallor

•B/l pedal edema

•No lymphaedenopathy 

O/E

•Pt was in altered sensorium 

•Not oriented to T/P/P

•GCS:-E2V2M4

•VITALS

PR:86 BPM

BP:90/50 mmhg

Spo2:-98% on RA

On 13/07/21

BP 120/90 mmhg

PR -92/min

CVS

S1 S2 + ,no murmurs

RS:BSE+,NVBS

P/A:Soft,NT

CNS

Neck stiffness+

Tone:

Hypotonia in b/l LL

Power

Left UL 3/5

Left LL 1/5 

Right UL &LL 0/5

Reflexes:

2+,plantar:withdrawl

INVESTIGATIONS 

CBP


CUE



APTT



PROTHROMBIN TIME


TROPONIN 1



BLOOD SUGAR RANDOM


SERUM ELECTROLYTES(Na,k,cl)


ABG


BLOOD UREA 


CREATININE


LIVER FUNCTION TEST



REPORT



CHEST RADIOGRAPHY



MRI


●CSF analysis 


INVESTIGATIONS ON 13/07/21


LIVER FUNCTION TEST 



CSF ANALYSIS 






BACTERIAL CULTURE AND SENSITIVITY REPORT




CYTOLOGY 


HIV TEST


HCV TEST

C REACTIVE PROTEIN

HBsAg



2D ECHO



REPORT

RADIOLOGY









PROVISIONAL DIAGNOSIS

•Meningitis-bacterial/TB
•CVA(embolic infarcts in B/L cerebral hemisphere)
•Hyponartemia
•Chronic nutritional hypoalbunemia
 13/7/21
Coronary artery disease 
HFIEF(EF 42%)

TREATMENT 


1)Inj CEFTRIAXON 2gm × IV ×BD
             1-×-1
2)Inj DEXMETHASONE 8mg×IV × BD
             1-×-1
3)INJ PAN 40gm × IV × OD
4)IVF NS 100 ml/hr
5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD
7)temp charting 4th hrly
8)TAB PCM 650mg ×RT ×sos

13/07/21


1)Inj CEFTRIAXON 2gm × IV ×BD
2)Inj DEXMETHASONE 8mg×IV × BD
3)INJ PAN 40gm × IV × OD
4)IVF NS 100 ml/hr
5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD
7)temp charting 4th hrly
8)T.ISONIAZID -300 mg - 1 tab/day
    T.RIFAMPSIN -600 mg-2 tab/day
     T.PYRIZINAMIDE-1500 mg -2 tab/day
     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day
                                         100mg-1/day
9)TAB ASPIRIN 150mg × RT×OD
10)TAB ATORVAS 40 mg ×RT ×OD


14/07/21

1)Inj CEFTRIAXON 2gm × IV ×BD
2)Inj DEXMETHASONE 8mg×IV × BD
3)INJ PAN 40gm × IV × OD
4)IVF NS 100 ml/hr
5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD
7)temp charting 4th hrly
8)T.ISONIAZID -300 mg - 1 tab/day
    T.RIFAMPSIN -600 mg-2 tab/day
     T.PYRIZINAMIDE-1500 mg -2 tab/day
     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day              100mg-1/day

  9)RT feeds- 100 ml milk with 3-4 scoops protein powder 4th hourly
100 ml free water 2hrly

10) tab Aspirin 150 mg RT /OD
11)tab Atorvas 40 mg RT /OD
12) tab Tolvaptan 15 mg RT /OD
13)  Oral suction 2 hrly
14) Position change 2 hrly
15) Tab Thyronorm 25mcg RT /OD
16) Nebulization with Budesonide/Ipratropium/6th hrly
17)Tab Benadon plus 40 mg RT /OD





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