A 21 YR OLD MALE WITH SOB SINCE 15 DAYS


Case History and Clinical Findings
C/O FEVER,COUGH,SOB SINCE 15 DAYS
C/O ABDOMINAL PAIN SINCE 3 DAYS
HISTORY OF PRESENTING ILLNESS :
PATIENT WAS APPARENTLY ALRIGHT 15 DAYS BACK,THEN HE HAD FEVER WHICH IS
INSIDIOUS IN ONSET,GRADUALLY PROGRESSIVE ,HIGH GRADE,
ASSOCIATED WITH CHILLS AND RIGORS.EVENING RISE OF TEMPERATURE PRESENT.
C/O COUGH WITH SPUTUM SINCE 15 DAYS,GREENISH COLOURED SPUTUM,COPIOUS
AMOUNT.
SHORTNESS OF BREATH SINCE 15 DAYS ,GRADE 2 ,RELIEVED BY TAKING REST .
NO ORTHOPNEA,NO PND.
DIFFUSE ABDOMINAL PAIN WHICH IS SQUEEZING TYPE OF PAIN .
NO H/O VOMITING,LOOSE STOOLS.
BURNING MICTURITION +
LOSS OF APPETITE +
H/O WEIGHT LOSS PRESENT 10-15 KGS IN 1 MONTH.
PAST HISTORY :
N/K/C/O DM,HTN,EPILEPSY,THYROID DISORDERS,TB,ASTHMA
HISTORY OF TONSILLECTOMY 10 YEARS AGO
PERSONAL HISTORY :
DIET : MIXED
APPETITE : DECREASED SINCE 15 DAYS
SLEEP : NORMAL
BOWEL AND BLADDER : REGULAR ( BURNING MICTURITION +)
NO ALLERGIES
FAMILY HISTORY :INSIGNIFICANT
GENERAL EXAMINATION :
PATIENT IS CONSCIOUS , COHERENT , COOPERATIVE
MODERATELY BUILT AND NOURISHED .
RIGHT CERVICAL LYMPH NODE PALPABLE
NO SIGNS OF PALLOR , ICTERUS , CYANOSIS , CLUBBING , EDEMA.
VITALS :
TEMPERATURE: 98.7F
PR - 84BPM
BP - 100/70 MMHG
RR - 20 CPM
SPO2 - 99% ON ROOM AIR
GRBS - 137 MG%
SYSTEMIC EXAMINATION :
P/A - SOFT,DIFFUSE TENDERNESS +
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD.
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH
SOUNDS HEARD
CENTRAL NERVOUS SYSTEM: NFND
COURSE IN THE HOSPITAL
21 YEAR OLD MALE PRESENTED WITH THE ABOVE MENTIONED COMPLAINTS. PATIENT
WAS EVALUATED CLINICALLY AND WITH APPROPRIATE INVESTIGATIONS. PATIENT WAS
TREATED SYMPTOMATICALLY WITH ANALGESICS AND ANTIPYRETICS AND GENERAL
SURGERY OPINION WAS TAKEN IN VIEW OF ?COLITIS ?CHOLECYSTITIS AND ADVISED
CONSERVATIVE MANAGEMENT. PATIENT WAS UPPER GI ENDOSCOPY I/V/O PAIN ABDOMEN
AFTER EATING FOOD BUT PATIENT WAS NOT WILLING FOR THE SAME. PATIENT
RECOVERED SYMPTOMATICALLY AND DISCHARGED IN STABLE CONDITION.
Investigation
26/04/23
HEMOGRAM
HB- 11.6 GM/DL
TLC- 9500CELLS/CUMM
PLT-2.5 LAKHS/CU.MM
28/04/23
HEMOGRAM
HB- 11.2 GM/DL
TLC- 4800CELLS/CU.MM
PLT-2.1 LAKHS/CU.MM
USG NECK ON 27/4/2023 :
IMPRESSION- CERVICAL LYMPHADENOPATHY (LEVEL IB @3-4MM ) ON RIGHT SIDE.
USG ABDOMEN ON 27/4/2023 :
IMPRESSION- MILD SPLENOMEGALY
 MINIMAL ASCITIS
 MESENTRIC LYMPHADENOPATHY(E/O MILD INFLAMMATORY CHANGES NOTED IN RIF WITH
FEW ENLARGED MESENTRIC LYMPH NODES IN RIGHT LUMBAR REGION,HYPOGASTRIC
REGIONAND RIF )
Diagnosis
GENERALIZED MYALGIAS
ACID PEPTIC DISEASE
CERVICAL AND MESENTERIC LYMPHADENITIS
Treatment Given(Enter only Generic Name)
INJ.BUSCOPAN IV SOS
TAB. TAXIM 200 MG PO/BD
TAB. DOXYCYCLINE 100MG PO/BD
TAB.ULTRACET HALF TAB PO QID
TAB.MYORIL 8MG PO BD
SYP.GRILLINCTUS 15ML PO TID
NEBULISATION WITH DUOLIN 4RTH HOURLY,BUDECORT 6TH HOURLY
Advice at Discharge
TAB. TAXIM 200 MG PO/BDX 2 DAYS
TAB. DOXYCYCLINE 100MG PO/BD X 2 DAYS
TAB. PAN 40 MG PO OD AT 8 AM X 1 WEEK
TAB.MYORIL 4MG PO BD X 3 DAYS
TAB.MVT PO OD X 10 DAYS
Follow Up
REVIEW AFTER 3 DAYS TO GM OPD
REVIEW WITH GASTROENETROLOGIST FOR UPPER GI ENDOSCOPY
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.

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