GENERAL MEDICAL CASE-3

 Harisha Samanapally

20 September 2021

This is online e-log book to discuss for patients de-identified health data shared after taking his/guardian sign informed consent

Here we discuss our individual patients problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best based inputs

 A 70 year old female came to the casuality with chief complaints of fever not associated with chills and rigor and generalised weakness since 10 days 

HISTORY OF PRESENT ILLNESS :

• Fever since 10 days and weakness

•Pedal Edema is seen 

•Patient took consent from local doctor and took medication for fever but fever was still persistent. 

•The night patient was admitted was drowsy and not cooperative,further investigation has been done 

HISTORY OF PAST ILLNESS: 

• No history of similar illness in the past

•No history of hypertension

•No history of diabetes mellitus

•No history of TB,cold,cough

•No history of COPD,asthma,SOB

•No history of epilepsy 

FAMILY HISTORY:

•No similar illness seen in the family

PERSONAL HISTORY:

• Diet: mixed 

•Appetite:Lost 

•Sleep:adequate 

•Bowel:normal 

•Urine output: decreased 

•Addictions: Alcoholic (occasionally) 

TREATMENT HISTORY:

•No history of surgeries in the past and no drug allergies 

GENERAL EXAMINATION:

•Patient is not cooperative, unresponsive not able to walk

• Pallor 

•No icterus

•No clubbing

•No cyanosis 

VITALS:

•Temperture:103°F 

•RR: 34cpm

•BP:80/60mm/Hg

•Pulse rate: 113bpm

•Spo2:95 

•GRBS:117mg/dl 

SYSTEMIC EXAMINATION

•CVS: S1&S2- normal 

•Respiratory: dyspnea 

•No abnormality in position of trachea

•Abdomen: obtuse shaped abdomen

•No abdominal mass is palpable 

•Bowel sounds are heard

CNS :  Patient is stupour not with complete             conscious mind 

•Difficulty in speech 

• Difficulty in recognising persons

• No signs of meningeal irritation

PROVISIONAL DIAGNOSIS:

•Septic encephalitis 

•viral pneumonia 

•Acute kidney disease 

INVESTIGATIONS: 

   Chest X-ray:


          Serum electrolytes;


          ECG REPORT:

CSF analysis of protein sugars:


Pedal edema:

  

Pallor palm
Bacterial culture test:

 


 
Hemogram:
 
Complete Urine examination
Renal function test


 TREATMENT:

Head end elevation

Oxygen supplementation 
  
IV fluids NS, RL @100ml/hour 

 Inj Pantop 40mg IV /OD

Inj Zofer 4mg/IV/TID

Inj Piptaz 2.25g/IV/TID 

Tab Dolo 650mg 

Tab. Levipil 500mg po bd

Inj Doxycycline 100mg IV BD 






What is the cause for her disease?

How did we diagnose it to be encephalitis when the patient has come with complaint of fever?

Is there a complete cure of encephalitis?

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