A 13 yr Male with Redness of eyes,Fever, Burning micturition and swelling of cheeks

A 13yr old male  who is student brought by parents with complaints of
Redness of eyes since the 5days
Fever since 4days
Burning micturition since 4days 

History of present Illness:
Patient was apparently asymptomatic 5days back after which he developed Redness of eyes,followed by Fever which is high grade  insidious onset, gradually progressive associated with burning micturition.
H/o yellowish discoloration of eyes 3days
H/o swelling in both cheeks since 2days 
H/o pain and difficulty in flexing left knee since 2days associated with progressive swelling
No H/o recent travel 
No H/o  similar complaints in the past 

PAST HISTORY 
N/k/c/o DM, Hypertension,  TB, Epilepsy,CVD, Asthama,Thyroid disorders

PERSONAL HISTORY

Single
Student
Diet :Mixed
Appetite: Lost
Sleep: adequate
Bowel and bladder regular
Addictions No 
No known Allergies 

GENERAL EXAMINATION

Pt is conscious coherent and cooperative 
Icterus present
No  pallor, cyanosis, clubbing generalized lymphadenopathy, edema 

Vitals

Temp: 101F
Bp :110/70 mm Hg 
PR :100 bpm 
RR: 18cpm
SpO2 : 98%
GRBS: 110mg/dl

SYSTEMIC EXAMINATION 

Cardiovascular system ::
No thrills 
S1,S2 are heard
No Murmurs 

Respiratory system::
No Dyspnea
No wheeze
Location of trachea :Central
Normal vesicular breath sounds
No adventitious sounds.

Abdomen ::
Shape of Abdomen -Schaphoid
No tenderness, palpable mass,
Normal hernial orifice
No bruits, free fluid 
No organomegaly 
Bowel sounds present.

CNS::
No focal neurological deficit 
GAIT: Limping Gait
Right eye 
left eyeleft cheek

Investigations::
X ray Hip
x ray Right  thighx ray left thigh
Chest X ray 
Xay left knee jointUltrasound:-2D ECHO
ECG on 2/7/2024ECG on  3/7/24

Hemogram,RFT, LFT, ESR,CRP, Aptt,PT, INR,CT,Bt . Dengue,widal test, malaria 

ASO titres: 311IU/ml
Treatment:-
1.Iv fluids .9 Ns ,RL @ 50ml /hr with optineuron
2.Inj.Ceftriaxone 1gm/IV/Bd
3.Inj.Doxycyclline 100mg/IV/Bd
4.Inj.Pan 40mg Iv/OD
5.Inj.Pcm 500mg IV/Stat
6.tab .Pcm 500mg /po/Tid 

Comments

Post a Comment

Popular posts from this blog

A 13 yr Male with Redness of eyes,Fever, Burning micturition and swelling of cheeks

Image
A 13yr old male  who is student brought by parents with complaints of Redness of eyes since the 5days Fever since 4days Burning micturition since 4days  History of present Illness: Patient was apparently asymptomatic 5days   back after   which he developed Redness of eyes,followed by Fever which is high grade  insidious onset, gradually progressive associated with burning micturition. H/o yellowish discoloration of eyes 3days H/o swelling in both cheeks since 2days  H/o pain and difficulty in flexing left knee since 2days associated with progressive swelling No H/o recent travel  No H/o  similar complaints in the past  PAST HISTORY  N/k/c/o DM, Hypertension,  TB, Epilepsy,CVD, Asthama,Thyroid disorders PERSONAL HISTORY Single Student Diet :Mixed Appetite: Lost Sleep: adequate Bowel and bladder regular Addictions No  No known Allergies  GENERAL EXAMINATION Pt is conscious coherent and cooperative  Icterus present No...
Read more

CKD with ADPKD

Image
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss out 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 evident based input.  This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have 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 comprehensing clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitt A 52 yr old male chief complaints  Swelling of Bilateral lower limbs since 1...
Read more

A 70 yr OLD MALE WITH IRON DEFICIENCY ANEMIA SECONDARY TO PER RECTAL BLOOD LOSS DUE TO SOLITORY RECTAL ULCER

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have 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 Case History and Clinical Findings  A 70 YEAR OLD FEMALE C/O LOOSE STOOLS 2 YEARS PATIENT WAS COMPLAINING  OF GENERAL WEAKNESS FROM 15 DAYS PAIN ABDOMEN SINCE 2 YEARS  WEIGHT LOSS SINCE 2YEARS  HISTORY OF PRESENT ILLNESS::- PATIENT WAS APPARENTLY ASSYMPTOMATIC 2 YEARS BACK SHE DEVELOPED LOOSE STOOLS ASSOSSIATED WITH BLOOD IN STOOLS NOT PAINFUL PAIN ABDOMEM RELIEVED AFTER PASSAGE OF STOOLS  WEIGHT LOSS SINCE 2 YEARS SIGNIFICANT  PAST HISTORY ::- PATIENT WAS COMPLAINING OF SIMILAR COMPLAINS FROM 2016 FOR WHICH SHE WAS DIAGNOSED TO HAVE SOLITORY RECTAL ULCER AD...
Read more