20 year old male with fever and vomitings
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A 20 year old male, resident of miryalguda came to the opd with chief complaints of fever since 8 days , vomitings since 8 days .
HISTORY OF PRESENTING ILLNESS-
Patient was apparently asymptomatic 8 days back . Then he had vomiting which was non projectile , watery associated with nausea, no retching when he was outside, then he went home and had 2 episodes vomiting which were 5 minutes apart ,non projectile , watery with blood clots( 2 per episode )
then went to the area hospital where he was given a tablet ( zofer) and asked to get endoscopy done.
He developed fever which was high grade , continuous, not associated with chills and rigors , rash , no diurnal variations.
He has history of consumption of outside food almost 5 times in the past week.
On tuesday ( dec 29)
He went to private hsptl in miryalguda, endoscopy was done .
report showed PANGASTRITIS
on that day, no history of vomitings but had continuous fever ,high grade .
And on Wednesday ( dec 30 ) he got admitted in the same hospital and was managed conservatively, . He had no episodes of vomitings but had continuous fever, high grade.
He was in the hospital for 3 days where he had episodes of fever in between.
On Saturday he had 3 episodes of vomitings watery, non projectile,
The doctor informed that the condition is severe can't be managed there and referred to another centre .
He was brought to our hospital on Saturday afternoon.
On Sunday he had 8 episodes of vomiting since 3:30 am which was non projectile , watery , immediately after consumption of water or food, without any retching.
He still has fever spikes.
He has complaints of headache and body pains
No history of burning micturition.
No history of cough or cold.
No history of neck stiffness.
No history of pain abdomen, loose stools.
No h/o NSAIDS intake
PAST HISTORY
No similar complaints in the past.
No history of diabetes, hypertension,asthma, tuberculosis, epilepsy.
PERSONAL HISTORY :
he has been staying at home past one year after completion of his training in ITI .
His daily routine :
he wakes up at 8:00 am in the morning, gets fresh up and takes breakfast occassionally and goes out with friends
then comes home and skips his lunch most of the time and sleeps and then goes out with friends in the evening and comes home at 10:00pm and has his dinner by 11:00pm
He takes mixed diet , appetite is normal, sleep is adequate, bowel and bladder movements are regular , no addictions
He consumes tea or coffee 10 to 20 times a day
FAMILY HISTORY:
not significant
GENERAL EXAMINATION:
patient is conscious, coherent and cooperative , well oriented with time, place and person
He is moderately built and nourished
He has no pallor , icterus , cyanosis, clubbing ,generalised lymphadenopathy, edema.
vitals :
temperature:
BP : 110/70 mmhg
PR :101 bpm
RR: 16cpm
SYSTEMIC EXAMINATION:
ABDOMINAL EXAMINATION
INSPECTION
- Shape - Scaphoid, with no distention.
- Umbilicus - Inverted
- Equal symmetrical movements in all the quadrants with respiration.
- No visible pulsation,peristalsis, dilated veins and localized swellings.
PALPATION
- Local rise of temperature present.
- Mild enlargement of liver,
regular smooth surface , rounded
edges , non tender, moving with
respiration non pulsatile
- SPLEEN palpable just below the costal margin, smooth,rounded margins, non tender.
PERCUSSION
- Hepatomegaly : liver span of 14 cms with 2 cms extending
below the costal margin
- Fluid thrill and shifting dullness absent
AUSCULTATION
- Bowel sounds not heard.
-No bruit or venous hum.
CNS
Higher mental functions intact.
No signs of meningeal irritation.
Normal sensory examination
Normal motor examination.
Cerebellar signs are absent.
CVS :
S1 S2 heard, no murmurs.
RESP SYSTEM
Bilateral air entry present, Normal vesicular breath sounds on both sides.
PROVISONAL DIAGNOSIS:
fever under evaluation
pangastritis
INVESTIGATIONS :
Endoscopy ( outside the hospital )
On 3/12-
On 4/12
TREATMENT:
On 3/12
1. NBM
2. Inj.PAN 40mg in 100ml NS for 1 hr IV Stat
3. Inj.NEOMAL 1gm IV/SOS
4. Moniter vitals 4th hrly
5. Inform SOS
6. T.DOLO 650mg /po / tid
On 4/12
1. IVF @75ml/hr ( 2 ONS , 2ONL)
2. Inj.ZOFER 4mg IV/ TID
3. Inj.PANTOP 40mg IV/BD
4. Tab. DOLO 650 mg /po /tid
5. Inka.NEOMAL 1gm IV/SOS
6. Moniter vitals 4th hrly
7. Inj. METROGYL 500mg IV/BD
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