Presentation on theme: "Case Presentation on Infectious Disease Presented By:- Vijay. Singh."— Presentation transcript:
Case Presentation on Infectious Disease Presented By:- Vijay. Singh
IP NO : DOA : UNIT :VII DEP: MEDICINE SEX : MALE AGE : 42 YEARS WEIGHT : 68 Kg
SUBJECTIVE Patient came with a complain of Fever, Headache and Breathlessness Sever and generated neck stiffness and pain. History of Present Illness C/o fever from 10 days a/w chills and rigors Bitter taste in mouth and vomiting. C/o of headache from last 8-10 days C/o of vomiting. Only one episode yet, Not projectile,immediate after food. Breathlessness on lying down & on walking about 500 metres
Cough with sputum Past History No h/o of DM/HTN/Epilepsy Habits Alcoholic – About 2-3 times / month (90 ml) Smoking – (Beedi) From last 20 years (1 pack/day) Diet- Mixed Appetite- Decreased Bowl & Bladder- Normal Sleep - Adequate
Physical Examination Patient is conscious, co-operative & alert. PR: 88 bmp B.P: 110/70 mmHg Temperature: 109 F P¯ I¯ C¯ C¯ L¯ E¯ Systemic Examination CNS: Neck rigidity (minimal), Kernigs (Negative) CVS: S1 S2 +, No Murmur R.S: NVBS +, No added sound. P/A: Hepatomegaly and tenderness is seen.
INVESTIGATIONNORMAL VALUE05/107/108/1 Hb ( gm/dl ) Tc (Cells/ cmm) 4000 to 11,0008,200 D.C ( % ) B M 3-72 L E 1-34 P ESR (mm/hr) 0 to 2072 BL. U (mg/dl) S.C (mg/dl) BLOOD PLATELETS lakhs2.14 lakhs Widal Test Possitive HIV Nigative CSF Prof mg/dl Sy 57 mg/dl pH Alkaline Sp. G 114 mol/ 2 Cells 20 cells/mm3
INVESTIGATIONNORMAL VALUE07/108/1 CSF Fluid Analysis Chloride115 to mg /dl Glucose50 to mg/ dl Protein15 to 40288mg /dl LDH104 IU/dl Urine Analysis AlbuminPresent SugarNil Pus Cells4-6 E.P Cells1-2 CSF Culture and SensitivityOccasional pus cells seen Organisms not seen Volume- 1.5 ml Color- S. reddish Appeareance- Turbid Cell count: 100%
CXR: Small cyst area are seen in both lower zone. Chest X-Ray:- P/A view - Cavities are seen which suggests presence of TB Gram Staining of Sputum – Positive (+ve) Ultrasound of Abdomen and Pelvis on 09/01/12 Mild Hepatomegaly (Grade –I)
Assesment Based on the Subjective and objective evidence of fever,breathlessness,cough, +ve CSF Culture and neck stiffness, +ve gram staining of sputum. The Patient is diagnosed with Tuberculosis, Meningitis and Bronchopneumonia.
Planning Suggestion to Physician Ondansetron may cause Bronchospasm and so instead some other type of antiemetics may presecribed E.g: Domperidone. Pantoprazole has ADR of bronchitis, cough, sinusitis and neck pain, so it should be replaced with Ranitidine Sparfloxacin should not be given with NSAIDs, there are chances of developing seizures Paracetamol increases the risk of lever damage in alcoholics and the person is already diagnosed with Hepatomegaly. Prescribe some 1 st line antitubercular drug.
Advice to Patient Adhere to dose regimen Take meal with Fatty Diet Maintain Hygienic Condition Do not split and cough in public. Avoid going out or in area where pollution is more. (to avoid bronchopneumonia condition)