Viral pyrexia with acute gastritis

 General medicine case report


HELLO GUYS ,This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Chief complaints:-


A 38 year old female came to casuality with chief complaints of fever and vomitings since 3 days.


History of present illness:-

Patient was apparently asymptomatic  3 days back then she developed fever which is of low grade and associated with chills and rigors and are relived on medication.

Vomting since 3days  of 2episodes daily which was non-bilious and no projectile , containing food particles. History of cold and cough (non productive) were present since 3 days.

No complaint of ‘pedal oedema ,decreased urine output and abdominal distension’.

No complaint of chest pain , palpitations and sob.

History of past illness:-

N/k/c/o HTN, DM, TB, Asthma, CVA, CAD, Epilepsy.


Personal history:-

Marital status:- married

Appetite:- lost

Diet:- mixed

Bowels:- regular

Micturition:- normal

No known allergies.


Family history:- not significant.


Physical examination:-

General examination:-

Patient is c/c/c with moderate build and moderate nourishment 


Pallor:- no

Icterus:- no

Cyanosis:-no

Lymphadenopathy:- no

Malnutrition:-no

Dehydration:-no

Clubbing:- no


Vitals:-

Temperature:- Afebrile

Pulse rate:- 90BPM

Respiration:-22 CPM

Bp:- 70/50 mm/ hg

Spo2:- 98%

GRBS:-140 mg/dl


Systemic examination:-

CVS :-s1 and s2 heard.No murmurs.

Rs:-BAE+,NVBS

P/A:-soft and non-tender.

CNS:-No focal deformities.


INVESTIGATIONS:-

1)Hemogram

Haemoglobin- 9.9gm/dl

TLC- 4500

Neutrophils-88%

Lymphocytes- 8%

Eosinophils-01%

Monocytes-03%

Basophils-00 %

PCV-28.4vol%

MCV-77.4fl

MCH-27.0pg

MCHC-34.9%

RDW-CV-12.9%

RDW-SD-35fl

RBC COUNT-3.67millions/cu.mm

PLATELET COUNT-1.53 lakhs/cu.mm


LFT:-

Total bilirubin-0.95mg/dl

Direct bilirubin-0.21mg/dl

SGOT-46IU/L

SGPT-13IU/L

Alkaline phosphate -108IU/L

Total proteins -4.8 gm/dl

Albumin-1.41gm/dl

A/G ratio-0.42


RFT:-

Urea-24mg/dl

Creatinine-1.1mg /dl

Uris acid-3.1mg/dl

Calcium-8.3mg/dl

Phosphorous -2.7mg/dl

Sodium-138mEq/L

Potassium -4.1mEq/L

Chloride-96mEq/L



Hemogram:-





LFT




RFT



 

X-RAY

 

TPR

.
PROVISIONAL DIAGNOSIS:- Viral pyrexia with acute gastritis.











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