CASE PRESENTATION

By:Sobia Rehman (09-98)

BIODATA
Name: Syed Zeeshan Age: 30 years Sex: Male Address: Nazimabad Occupation: Works in office Date of admission: 16-dec-2013 Mode of admission: OPD

Presenting Complaints
Fever - since 1 week Abdominal pain- since 1 week Vomiting since - 1 week

History of presenting complaints

No known co-morbidities. According to the patient he was in usual state of health 1 week back then suddenly he developed fever. Fever was documented about 102 to 103F. Fever was continuous in nature but more in afternoon. Fever was associated with chills not rigors and it was relieved by taking Tab.pandol but comes back after few hours. There is no aggravating factors.

 Fever is also associated with weakness and bodyache.He was unable to perform daily routine work because of weakness during fever. Patient also complaints of vomiting which was sudden in onset non-projectile.He vomits 4 to 5 times per day. Quantity is about 3 to 4 cups, contains food particles, yellow in colour,no blood or mucus in it. It aggravates by taking food no relieving factors. It is associated with abdominal pain which is dull in nature, generalized and their is no relieving factors.There is no history of bleeding from gums,no brises,no melana,no heamoptosis.

Past Medical History

There is no history of such condition in past.No history of Diabets, Hypertension, Asthma, Hepatitis B AND Hepatitis C. There is no history of blood transfusion.

Past Surgical History

Appendectomy was done 12 years back.

Family History:
Father is diabetic Mother is hypertensive

Personal History
Appetite was normal before illness but now it is decreased. Sleep is normal. Urine and bowel habits are normal. He is not addicted to anything. Allergic history is not significant.

Drug History: He used some antibiotics for 1

week prescribed by general physician.

Current Medication:
Inj. Gravinate IV SOS Inj. N/S 1000 C.C IV 150ml/hour Inj. D/S 1000 C.C IV 100ml/hour Inj. Nospa IV stat Syrp. Ulsanic 10ml TDs Tab. Folic acid 5mg 1+0+1 Tab. Pandol 2+2+2

Socioeconomic History
He lives in 4 rooms house,well- ventilated with all basic facilities.they used boiled water.

Review of systems
Cardiovascular system:
Chest pain: +ve Shortness of breath: -ve Orthopnoea: -ve PND: -ve Oedema: -ve Palpitation: -ve Claudication: -ve

Respiratory system:
Cough: -ve Sputum: -ve Heamoptysis: -ve Hoarseness of voice: -ve Wheeze: -ve Snoring: -ve Day time somnolece: -ve

Gastrointestinal tract:
Indigestion: +ve Heart burn: -ve Jaundice: -ve Dysphagia: -ve Abdominal pain: +ve Nausea/vomiting: +ve Heamatemesis: -ve Diarrhea: -ve Melana: -ve Bleeding P/R: -ve

Genitourinary system:
Dysuria: -ve Frequency: -ve Urgency: -ve Hesitancy: -ve Nocturia: -ve Heamaturia: -ve Insentience: -ve Discharge per urethra: -ve

Hematological:
Bruises: -ve Gum bleeding: -ve Epistaxis: -ve Lumps: -ve

Musculoskeletal:
Joint pain: -ve Joint swelling: -ve Morning stiffness: -ve Back pain or neck pain: -ve Skin rashes: -ve Red eyes: -ve Dry mouth: -ve

Endocrine system:
Swelling in neck: -ve tremors: -ve Sweating: -ve Fatigue: +ve Thirst: -ve

Neurological system:
Headache: +ve Dizziness: -ve Vertigo: -ve Deafness: -ve Visual disturbances: -ve Fainting episodes: -ve Fits: -ve Weakness in arms and legs: -ve

Examinations GPE: Young male sitting on bed comfortably.

Well oriented in time, place and person.

Vitals:
Pulse: 80b/min

Bp: 110/80 mmHg R/R: 18braeths/min Tem: afebrile

Pallor: -ve Jaundice: -ve Clubbing: -ve Cyanosis: -ve Dehydration: -ve Pedal edema: -ve Jvp: -ve Lymphadenopathy: -ve Thyroid: -ve

Abdominal Examination
Inspection: Normal elliptical shape, no visible
pulsation and scar marks. No pigmentations. Umbilical Is inverted and centrally placed.

Palpation: Abdomen is soft non-tender, no

visceromegaly.

Percussion: No shifting dullness, no fluid thrill Auscultation: Bowel sound audible.3 to

5/min

Cardiovascular Examination
Inspection: no scar marks and no visible
pulsation.

Palpation: Apex beat at 5 intercostal space,

no heaves and no thrill.

Auscultation: S1+S2+0, No added

sounds,no murmurs.

Respiratory Examination
Inspection: Chest is moving symmetrically.
There is no visible pulsation, scar marks and pigmentation.

Palpation: Apex beat at 5 intercostals space.

trachea is centrally placed.

Percussion: Resonant on both sides. Auscultation: Normal vesicular breathing,

equal air entry on both sides. No added sounds.

CNS Examination
Glasgow Coma Scale : 15/15 Higher Mental Function: MMSE 30/30.
Fully consious,speech is normal. Well oriented in time place and person.

Cranial Nerve: All cranial nerves are intact Sensory system: intact

Motor System Examination

LEFT
TONE NORMAL RIGHT

NORMAL

BULK

NORMAL

NORMAL

POWER

5/5

5/5

REFLEXES

NORMAL

NORMAL

Investigations
CBC:
HB: 13.5 RBC: 4.52 HCT: 40 MCV: 89 MCH: 30 MCHC: 33 WBC: 6.2 Neutrophils: 45 Lymphocyets: 42 Monocytes: 13 Platelates: 14

Electrolytes
Na: 144 (136-146)M.Eq/L K : 3.3 (3.5-4.5) M.Eq/L Cl : 105 (98-107)M.Eq/L HCO3: 23 (22-26)M.Eq/L Lipase: 49 (13-60)IU/L SGPT:175 upto 31 IU/L Amylase:130 (28-100)IU/L

Chest X-ray: Normal

Ultrasound Abdomen:
Mild bilateral pleural effusion seen. Thicked wall gall bllader due to ascites. Mild ascites seen. Normal sonography of liver,pancrease,spleen and kidneys.

Immunochromatographic Ict Malaria

ICT PF : Negative ICT PV :Negative

Dengue Serology:
Dengue NS-1 Antigen: Detected

Differential Diagnosis
Dengue fever Malaria Typhoid

Management Plan
Hydrate the patient Give anti-emetic and anti-pyretic drugs Send labs again( platelates count) If not improved than transfuse blood Observe for bleeding.