20year old male with fever since 4 days and pain abdomen since 1 day

 20year old male came with c/o fever since 4 days and pain abdomen since 1 day 

Pt was apparently asymptomatic 4days back then had fever for 4 days, intermittent, high grade fever, associated with chills and rigors.

Pain abdomen in epigastric region, non radiating throbbing type of pain associated with loss of appetite, not associated with nausea, vomitings, loose stools, constipation, Malena, 

Vomitings 2 episodes, non bilious, non projectile and food as content, watery stools (4-5 episodes), no mucous/blood/dark coloured stools (subsided now)

No h/o Malena, petechiae, hematuria, giddiness, sweating, headache, palpitations, SOB

Pt is n/k/c/o DM, HTN, Epilepsy, CAD, CVA

Personal History:

Diet- mixed

Appetite- normal

Sleep- adequate

Bowel and bladder movements- regular

No addictions

General Examination:

Patient is C/C/C

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals at admission:

Temp.-100 F

PR- 91 bpm

BP- 110/70 mmHg

RR- 17 cpm

SpO2- 99% at RA

Systemic Examination:

CVS- S1S2 heard, no murmurs

RS- BAE+ , NVBS+

CNS- NAD

P/A- Soft, mild tenderness in epigastric region

Investigations- 

Provisional diagnosis- Viral Pyrexia with Thrombocytopenia

Treatment-

IVF- RL, NS @75ML/HR

Inj. PANTOP 40mg IV/OD

Inj. ZOFER 4mg IV/SOS

Inj. NEOMOL 100ml (IV/SOS if temp >100f)

T. PCM 500mg PO/TID

I/O charting

Temperature charting

W/f for bleeding manifestations and postural hypotension

80 YRS OLD MALE CAME TO CASUALTY WITH C/O LOSS OF CONSCIOUSNESS (FOR HALF AN HOUR) C/O INVOLUNTARY BOWEL AND BLADDER INCONTINENCE AND SLURRED SPEECH

80 yrs old Male came to casualty with 

C/O loss of consciousness (for half an hour)

C/O involuntary bowel and bladder incontinence and slurred speech since 4am today(19/12/21)

HOPI

Patient was apparently asymptomatic till 4:00am today got up from bed and walked to washroom ,while walking near the door at 4:00am,patient slipped and fell on the ground-sustained injury to back and head.

He had loss of consciousness for half an hour and then regained.Conscious spontaneous with no involuntary movements,froth from mouth.

H/O involuntary micturition and defecation present 

H/O slurred speech present after fall

On presentation patient is conscious,confused,slurred speech present.

Past history 

N/K/C/O HTN,DM,TB,epilepsy,CVA,CAD

Personal history 

Diet -mixed

Appetite-normal

Bowel movements-irregular 

He is a toddy drinker and smokes chutta 

Family history 

Not significant 

General examination 

Pt is conscious 

Vitals

Temp-Afebrile 

Bp-120/60mmHg

PR-90bpm

Spo2-99% on RA

Systemic examination 

CVS-S1,S2 +

RS- BAE+,NVBS

P/A-soft,non tender

CNS-

He is conscious and confused 

Speech is slurred 

Motor examination

Tone -increased on rt side

Reflexes-

          Rt.          Lt 

       B. 2+.          +

       T. 2+.          +

       S. 2+.          +

       K. 3+.          +

       A. 3+.          +

Planters-B/L mute

Sensory examination 

Flexion movement to pain

Provisional diagnosis 

Acute ischemic stroke - secondary to acute infarct in right frontal and parietal region with ? Denovo DM -2

Investigations

On 20/12/21

CBP

Serum electrolytes

Treatment 

1. Inj.  Mannitol 100 ml IV/STAT

2. Inj. Lasix 80 mg IV/STAT

3. Inj. Actrapid 10U in 25%D over 45min

4. Inj. Labetalol 20 mg IV/STAT

5. Neb with salbutamol 2respules

6. Tab. Ecospirin 150 mg po/stat

7. Tab. Atorvas 40 mg po/HS

8. Bp monitoring 2nd hourly 

9. Grbs-6th hourly 

10. I/O charting

Soap notes.

21/12/21

Pt is drowsy , but arousable to deep painful stimulus

Gcs - E3V2M4

Temp- 98.7f

Bp- 140/90mmhg

PR - 100bpm

RR- 18cpm

Spo2- 97% at room air

Grbs-120mg/dl

I/0- 1550/1450ml

Rs -bae+

Cvs- s1s2+

P/a- soft , bs+

Cns- pupils  lt eye underwent cataract surgery, Rt eye sluggish reacting to light

Corneal conjuctival- present b/l

Dolls eye- present 

Tone-

             Rt.                 Lt

Ul.          N                   Dec

LL.        Dec.             dec

Power

             Rt.                 Lt

UL.        3/5.              3/5

LL.         2/5.              2/5

Reflexes

            Rt.           Lt

Biceps -               -

Triceps -             -

Supinator-           -

Knee-                   -

Ankle.   -              -

Plantar flexors.    Flexors

A-

Acute ischemic stroke ( lacunar infract in Rt frontal and occipitotemporal lobe)

Chronic infracts in Rt lentiform nucleus 

Denovo HTN

H/0 chronic smoker and alcoholic 

P-

Rt feeds 100ml milk protein followed by 50ml free water 4th hrly

Ivf NS RL @ 75ml/hr

Tab ecosporin 75Mg po od

Tab atorvastatin 20mn po od

Investigations

Icu bed no5

Pt is conscious, not oriented to time place person

Gcs - E4V3M5

Temp- 98.7f

Bp- 140/90mmhg

PR - 100bpm

RR- 18cpm

Spo2- 97% at room air

Grbs-120mg/dl

I/0- 1200/1450ml

Rs -bae+

Cvs- s1s2+

P/a- soft , bs+

Cns- pupils  lt eye underwent cataract surgery, Rt eye sluggish reacting to light

Corneal conjuctival- present b/l

Dolls eye- present 

Tone-

             Rt.                 Lt

Ul.          N                   Dec

LL.          N.             dec

Power

             Rt.                 Lt

UL.        3/5.              3/5

LL.         2/5.              2/5

Reflexes

            Rt.           Lt

Biceps -               -

Triceps -             -

Supinator-           -

Knee-                   -

Ankle.   -              -

Plantar flexors.    Flexors

A-

Acute ischemic stroke ( lacunar infract in Rt frontal and occipitotemporal lobe)

Chronic infracts in Rt lentiform nucleus 

Denovo HTN

H/0 chronic smoker and alcoholic 

P-

Rt feeds 100ml milk protein followed by 50ml free water 4th hrly

Ivf NS RL @ 75ml/hr

Tab ecosporin 75Mg po od

Tab atorvastatin 20mn po od

A 17 YEAR OLD MALE WITH IATROGENIC CUSHING'S SYNDROME

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A 17 YEAR OLD MALE WITH IATROGENIC CUSHING'S SYNDROME 

A 17 Year old male came to the OPD with 

Chief complaints 

• Puffiness of face 

• Striations all over the body 

• Blurring of vision 

• Ulcers 

History of present illness 

• Patient was asymptomatic 2 years ago 

and then he suddenly developed rashes all over the body ( Ring worm ) for which he was taken to the ayurvedic clinic and was prescribed some medications ( unknown medication ) and he is on medication for 1 year .

• He also mentioned he went to a private local hospital because his rash did not subside. where he was prescribed with steroids and on these medications for 1 year .

• 6 months before he visited kamineni for the first time because his symptoms didn't subside and on irregular medication . He was prescribed some topical applications and medications . 

Past History 

Not a k/c/o DM , HTN , Epilepsy , TB , Bronchial asthma , CAD , CVA , Thyroid disorders  .

Personal History 

Diet - Mixed 

Appetite - More than Normal 

Sleep - Decreased 

Bladder & Bowel  movements - Regular

No addictions 

Family History 

No H/o DM , HTN , CVA , CAD , Bronchial asthma , Thyroid disorders , epilepsy in the family .

General Examination 

Patient is conscious, coherent and cooperative  

Moderately built and moderately nourished 

No Pallor 

No Icterus 

No cyanosis 

No Clubbing 

No koilonychia 

No Lymphadenopathy 

Slight pedal oedema

VITALS 

Temperature - 104°F

Pulse rate - 96 bpm

Respiratory Rate - 16 cpm

BP - 140/80 mmHg 

SPO2 at room air - 98%

GRBS - 114 mg/dl 

SYSTEMIC EXAMINATION 

Cardiovascular system 

INSPECTION

Chest wall is bilaterally symmetrical .

No precordial bulge .

No visible pulsations, engorged veins, scars, sinuses .

PALPATION

JVP - Normal 

APEX BEAT - Felt in the left 5 th intercostal space in the midclavicular line .

AUSCULTATION

 

S1 S2 heard .

No murmurs 

Respiratory system 

Position of the trachea  - Centre 

Bilateral air entry +

Normal vesicular breath sounds heard 

No added sounds .

 

Per abdomen 

Abdomen is soft , non tender 

No organomegaly

Bowel sounds heard 

No palpable mass 

No free fluid .

Central nervous system 

Patient is Conscious 

Speech: normal

No signs of Meningeal irritation

Motor & sensory system: normal

Reflexes: normal

Cranial nerves: intact .

Provisional diagnosis 

IATROGENIC CUSHING'S SYNDROME 

Treatment 

SALT RESTRICTED DIET  

DIABETIC DIET

T. TELMA - AM (40/5) mg PO /OD 

T .METFORMIN 500mg / PO/OD 

T. ITRACONAZOLE 100mg / PO /BD 

LULIFIN CREAM FOR L/A 

TAB . LEVOCITREZIN 10mg 

TAB . NICARDIA 10mg SOS