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50 YRS OLD MALE WITH VIRAL PYREXIA & THROMBOCYTOPENIA WITH AKI &PLEOMORPHIC ADENOMA OF RT PAROTID GLAND & OBSTRUCTIVE JAUNDICE


No h/o loose motions , burning micturition , dyspnea , headache , darkstools , bleeding from gums .

PAST HISTORY:-

k/c/o DM since 6 years on medication metformin 500 mg 

K/c/o HTN since 3 years not on regular medication and patient does not know the name of medication  

FAMILY HISTORY: not significant 

DAILY ROUTINE : He used to wake up at 6:00AM,Completes his needs & Breakfast by 10: Am,Then goes to his work (BARBAR).

PERSONAL HISTORY: Sleep:Adequate

                                 Diet : mixed 

                                Appetite : normal 

                                Baledder &Bowel:regular

  H/o alcohol intake daily 90 ml from 10 yrs .

GENERAL EXAMINATION:-

O/E : pt is c/c/c

No pallor , cyanosis , clubbing , 

Icterus (+ ), edema upto the ankles 




VITALS:-

PR: 80 bpm

Bp: supine :110/70 mmhg 

       Prone: 110/70 mm hg 


Spo2 : 97 %

CVS : s1s2

Cns : NAD

RS: BAE

P/A: soft , Bs , NT 

       on percussion : hepatomegaly

INVESTIGATIONS:-
USG ABDOMEN: Gall bladder oedema 

:

USG OF SWELLING OVER RT MANDIBLE:-  

E/o 4.5x3cm solid cystic lesion  with solid component showing increased vascularity noted in superficial lobe of right parotid extending into deep lobe.

Enlarged 1b cervical lymph node measuring 9mm along SAD   

CHEST X-RAY:-

ECG:-

PROVISIONAL DIAGNOSIS:-

Viral Pyrexia with thrombocytopenia with AKI with pleomorphic adenoma with obstructive jaundice

TREATMENT:-

1) IVF NS , RL @150ml /hr 

      2)Grbs charting 8 th hrly 

      3) Temp charting hrly 

DAILY UPDATE:-

27/3/22


50year /male


S-C/o Fever , c/o vomitings subsided 


O/E:No pallor/Cyanosis/Clubbing. 

Icterus ( ), edema above the ankles 


Enlarged 1b cervical lymph node measuring 9mm along SAD  


Temp:98.4f 

PR:98bpm

RR:22cpm

BP:supine :130/90mm of hg

       Prone : 130/90mm of hg 

CVS:S1,S2 heard,no murmurs

RS:BAE ,NVBS heard

P/A:SOFT,NONTENDER,BS , Hepatomegaly ( )

A: Dx-viral pyrexia with thrombocytopenia with AKI with pleomorphic adenoma with obstructive jaundice

Rx:

1) IVF NS , RL @150ml /hr 

      2)Grbs charting 8 th hrly 

      3) Temp charting hrly 

      4) Strict I/o charting


Amc UPDATE 

28/3/22


50year /male


S-C/o Nausea , c/o fever  subsided 

O-

O/E:No pallor/Cyanosis/Clubbing. 

Icterus ( ), edema above the ankles 


Enlarged 1b cervical lymph node measuring 9mm along SAD  


Temp: 98.4 f

PR:89 bpm

RR:20 cpm

BP:supine :130/80 mm of hg

       Standing : 130/80 mm of hg 


I/O 2600/1500ml


CVS:S1,S2 heard,no murmurs

RS:BAE ,NVBS heard

P/A:SOFT,NONTENDER,BS , Hepatomegaly ( )

Hb:11.3

Plt count:20000

TLC:10600

Sr creatinine:4.9 mg/dl

Blood urea:101mg/dl

Total Bilirubin :6.30 mg/dl

Direct Bilirubin:4.42 mg/dl


Dx:-viral pyrexia with thrombocytopenia with AKI with pleomorphic adenoma with obstructive jaundice

Rx:

1) IVF NS , RL @150ml /hr 

      2)Grbs charting 8 th hrly 

      3) Temp charting hrly 

      4) Strict I/o charting

5. Inj Zofer 4mg IV /sos

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