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 BreathlessnessSever 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 daysC/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 HistoryNo h/o of DM/HTN/Epilepsy
HabitsAlcoholic – About 2-3 times / month (90 ml)Smoking – (Beedi) From last 20 years (1 pack/day)
Diet- MixedAppetite- DecreasedBowl & Bladder- NormalSleep - Adequate
Physical ExaminationPatient is conscious, co-operative & alert. PR: 88 bmpB.P: 110/70 mmHgTemperature: 109 FP¯ I¯ C¯ C¯ L¯ E¯Systemic ExaminationCNS: Neck rigidity (minimal) , Kernig’s (Negative)
CVS: S1 S2 + , No MurmurR.S: NVBS + , No added sound.P/A: Hepatomegaly and tenderness is seen.
Provisional DiagnosisTBMeningitisBronchopneumonia
Objective
INVESTIGATION NORMAL VALUE
05/1 07/1 08/1
Hb ( gm/dl ) 13-18 11
Tc (Cells/ cmm) 4000 to 11,000
8,200
D.C ( % ) B 00-01 0
M 3-7 2
L 25-33 14
E 1-3 4
P 40-75 80
ESR (mm/hr) 0 to 20 72
BL. U (mg/dl) 15-40 0.8
S.C (mg/dl) 0.9 - 1.5 19
BLOOD PLATELETS 1.3 - 4 lakhs 2.14 lakhs
Widal Test Possitive
HIV Nigative
CSF
Prof 246.3 mg/dl
Sy 57 mg/dl
pH Alkaline
Sp. G 114 mol/ 2
Cells 20 cells/mm3
INVESTIGATION NORMAL VALUE 07/1 08/1
CSF Fluid Analysis
Chloride 115 to 130 107 mg /dl
Glucose 50 to 80 108 mg/ dl
Protein 15 to 40 288mg /dl
LDH 104 IU/dl
Urine Analysis
Albumin Present
Sugar Nil
Pus Cells 4-6
E.P Cells 1-2
CSF Culture and Sensitivity
Occasional 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 .
BRAND NAME
GENERIC NAME DOSE FREQUENCY
DATE DATE END
Inj-C-tri (I.V) Ceftriaxone + Salbactum
3 gm. 1-0-1 05/01 11/01 (1gm)
Inj- Emeset (I.V)
Ondansetron 4 mg 1-0-1 05/01 11/01
Inj. Pantodec (I.V)
Pantoprazole 40 mg 1-0-1 05/01 11/01
Inj. Gentamycin (I.V)
Gentamycin 80 mg 1-0-1 05/01 Stopped
Salbair-I(Nebulaizer)
Salbutamol 1-1-1 06/01 11/01
Budate (Nebulaizer)
Budesonide 12-Hourly 06/01 11/01
Syrup Ambrolite-S
Ambroxol 2-2-2 tbsp.
06/01 11/01
Inj. Endocin (I.V)
Amikacin 500mg 1-0-1 06/01 11/01 Stopped
Tab. Dolo-650
Paracetamol 650 mg
S.O.S(It temp >105 F)
05/01 11/01
Inj. Metrogyl (I.V)
Metronidazole 100 ml 1-1-1 06/01 11/01
Syrup-Chitralka
Disodium Hydrogen Citrate
2-0-2 (in water)
08/01 11/01
Tab. Wispar Sparfloxacin 1-1-1 08/01 11/01
Tab Claribid Calrithromycin 100 mg
1-0-1 08/01 11/01
Tab. Diclofenac-P
Diclofenac 100 mg
S.O.S 08/01 11/01
Inj Streptomycin (Deep I.M)
Streptomycin 10/01 11/01
Syrup Digene GEL
(Mg(OH)2Simethicone, Na carboxymethylcellulose, Al(OH)3
8 gm (max)
2-2-2 11/01
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 NSAID’s , 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 1st 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)
Thank You