14 YEAR OLD MALE WITH PERIPHERAL CYANOSIS

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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 a diagnosis and treatment plan.

CHIEF COMPLAINTS:

C/O • FEVER since 3 days

• LOOSE STOOLS since 3 days.

•VOMITING since 3 days.

• bluish discoloration of fingers of upperlimb simce yesterday.

History of present illness:

Patient was apparently asymptomatic 3 days back then he developed

Fever, which is high grade fever, not relieved on taking medication.

Loose stools, 3-4 episodes/ day till yesterday.

H/O 3 episodes of vomiting on day 1, which is bilious, non projectile.

Associated with head ache in occipital region since 3 days.

• from yesterday patient developed bluish discoloration of fingers.

PAST HISTORY:

Not a known case of, hypertension, diabetes,CAD, EPILEPSY, ASTHAMA.

H/O injury to index finger and surgery done to finger at 1 year of age.

FAMILY HISTORY:

NO SIMILAR COMPLAINTS IN THE FAMILY.

Personal history:

Diet- mixed

Appetite- normal

Bowel and bladder movements- Regular

Allergies- No

Addictions- No

GENERAL EXAMINATION:

Pt is conscious, coherent and cooperative

At the time of presentation hand and feet are cold compared to forearm.

CYANOSIS - PRESENT

No pallor, no icterus, , no clubbing, no lymphadenopathy.

VITALS- day 1

TEMP-101.4 F

BP-100/60

Pulse rate-86bpm

RR- 18cpm

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION:

Umbilicus inverted , No abdominal distention,no visible pulsations,scars and swelling.

PALPATION: Soft, non tender, no organo megaly.

AUSCULTATION:

BOWEL SOUNDS HEARD

Cardio vascular examination:

No visible pulsations, scars, engorged veins. No rise in jvp

Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

S1 S2 heard . No murmurs.

Respiratory system : Shape of chest is elliptical, b/l symmetrical.

Trachea is central. Expansion of chest is symmetrical

Bilateral Airway Entry - positive

Normal vesicular breath sounds

CNS EXAMINATION:

No signs of meningeal signs

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right. Left.

Biceps. ++. ++

Triceps. ++. ++

Supinator ++. ++

Knee. ++. ++

Ankle ++. ++

Gait: normal.

INVESTIGATIONS:

RBS- 80mg/dl

DIAGNOSIS: Acute Gastroenteritis,Peripheral cyanosis(1episode-Resolved) with cervical lymphadenopathy.

Treatment:

1. Tab. Paracetamol PO/TID

2. Temperature monitoring 4th hourly.

Day 3

AMC

14/M

S- Loose stools decreased.

O-

Patient is conscious coherent and cooperative

BP- 100/60mm hg

PR- 98 bpm

RR- 18cpm

TEMP-101.4 F @ 8 am

SpO2- 99% on RA

CVS-S1S2+

R/S-BLAE+, NO ADDED SOUNDS.

P/A-soft , non tender

CNS-NFND.

Diagnosis: Acute Gastro enteritis,peripheral cyanosis(1episode-Recovered),Generalised Lymphadenopathy

Treatment:

1. IVF NS, RL @100 ml/hr

2.TAB PCM 650MV PO/TID

3.TEMPERATURE MONITORING 4TH HOURLY

AMC bed 1

Day 4

S-complaints of loose stools subsided

C/o one episode of vomiting (no food particles) yesterday night

Fever spikes @4pm 103F

@12am 101.6F

O-

Patient is conscious coherent and cooperative

BP-90/60mmHg

PR-92bpm

TEMP-98.4F

SPO2-96% at RA

GRBS-104mg/dl @8AM

CVS-S1S2+

R/S-BAE+,NVBS-heard

P/A-soft and mild tenderness in umblical region, no organomegaly

CNS-NFND

A-

ACUTE GE with PERIPHERAL CYANOSIS ( 1episode -resolved ) with GENERALISED LYMPHADENOPATHY

P-

1.IV FLUIDS @NS RL @100 ml/hr

2.TAB.PCM650mg PO TID

3.INJ.MONOCEF 1gm IV BD

Urine and blood cultures negative

Day 5

S- C/O loose stools 4 episodes in 4-7 pm yesterday

1 episode today morning

O-

Patient is conscious coherent and cooperative

BP-90/60mmHg

PR-84bpm

TEMP-100.1F

SPO2-96% at RA

GRBS-103mg/dl @8AM

CVS-S1S2+

R/S-BAE+,NVBS-heard

P/A-soft and no organomegaly

CNS-NFND

Urine and blood cultures negative

A-

ACUTE GE with PERIPHERAL CYANOSIS ( 1episode -resolved ) with GENERALISED LYMPHADENOPATHY

P-

1.IV FLUIDS @NS RL @100 ml/hr

2.TAB.PCM650mg PO TID

3.INJ.MONOCEF 1gm IV BD

Day 6:

S- C/O loose stools 3 episodes yesterday (semisolid consistency),

Rashes over fingers( nail bed area)

Fever spikes+

O-

Patient is conscious coherent and cooperative

BP-100/50mmHg

PR-96bpm

TEMP-101.2F

SPO2-98% at RA

GRBS-98mg/dl @8AM

CVS-S1S2+

R/S-BAE+,NVBS-heard

P/A-soft , no tenderness and no organomegaly

CNS-NFND

Urine and blood cultures negative

A-

? Enteric Fever with PERIPHERAL CYANOSIS ( 1episode -resolved ) with GENERALISED LYMPHADENOPATHY

P-

1.IV FLUIDS @NS RL @75 ml/hr

2.TAB.PCM650mg PO TID

3.INJ.MONOCEF 1gm IV BD (Day 4)

4.TAB AZITHROMYCIN 1gm PO/OD ( Day 2)

28/ 10/22

S: fever spikes+

O-

Patient is conscious coherent and cooperative

TEMP-103.5F

BP-110/60mmHg

PR-104bpm

CVS-S1S2+

R/S-BAE+,NVBS-heard

P/A-soft and nontender, no organomegaly

CNS-NFND

A-

PYREXIA UNDER EVALUATION SECONDARY TO ?VIRAL ?ATYPICAL WITH ACUTE GASTROENTERITIS WITH MESENTERIC,CERVICAL,INGUINAL LYMPHNODES WITH PERIPHERAL CYNOSIS ( 1 episode RESOLVED)

P-

1.IV FLUIDS @NS RL @75ml/hr

2.TAB.PCM 650mg PO TID

3.MONITOR VITALS

4.TEMPERATURE MONITORING.

29/ 10/22

14/M

S: Fever spikes+, pain at the tip of fingers of both palms, cyanosis+

O-

Patient is conscious coherent and cooperative

TEMP-105.2F

BP-100/60mmHg