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