60 year old female with high grade fever,weakness since 10 days
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Systemic Examination:
ECG:
2/1/23
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.
3/01/23
60 year old female patient who is a resident of pallipadu came with chief complaints of
•Fever since 10 days
•Generalised weakness since 10 days
•Backache since 10 days
History of presenting illness:
Patient was apparently asymptomatic 10 days back and then she developed high grade fever,sudden in onset, with chills and rigors , continuous,no evening rise of temperature
And patient also complains of backache since 10 days , continuous which is insidious in onset ,dull aching type,non radiating,with no aggravating and relieving factors
She also has complaints of body pains since 10 days for which she got medication from their local RMP but it is not subsided
As the symptoms didn't subside she went to a government hospital where she was diagnosed with low blood pressure and Decreased platelet and kept under observation.
As her condition doesnt improved she came to our hospital .
The patient is now having Bilateral pedal edema , pitting type up to knee.
Past History:
Patient has no similar complaints in the past
No surgeries underwent into the past
Not a known case of Diabetes mellitus, hypertension, coronary artery diesease,asthma, epilepsy, tuberculosis.
Personal History:
Patient takes mixed diet,
appetite is decreased,
Sleep-disturbed
Bladder and bowel movement are normal
Addictions:
Patient smokes chutta since 40 years 1-2 per day.
Patient has no known allergies
Family History:
No significant family History
Treatment History:
Antipyretics , Antibiotics (unknown)
General Examination
Patient is conscious coherent coopertive she is well built and well nourished.
Vitals:
Temperature: afebrile
BP- 90/70 mmHg
Pulse-80 beats per minute
RR- 15 cpm
Pallor- present
Icterus : absent
Cyanosis- absent
Lymphadenopathy-absent
Clubbing-absent
Generalised edema- absent
Bilateral pedal edema - seen
Abdominal Examination -
On Inspection:
Abdominal Distension is present
Umbilcus is at centre (slit like)
No dilated veins
No scars,sinuses.
Palpation:No local rise in temperature
Tenderness is elicited in the Right Hypochondrium .
No visible pulsations
No organomegaly
Percussion: Tympanic note heard over abdomen
Auscultation:
Bowel sounds heard
Cardiovascular system:
S1 S2 heard ,no murmurs
Respiratory system:Bilateral Air entry present
Normal vesicular breath sounds heard
Central Nervous system:
Higher mental function intact
Provisional Diagnosis:
Dengue shock syndrome with Thrombocytopenia ,with Acute Kidney injury ,Acute Liver injury.
Investigations:
Fever chart
Hemogram:
Dengue test:
Liver function tests:
1/1/23
2/1/23
Serum electrolytes:
1/1/23
3/1/23
Serum creatinine:
1/1/23
2/1/23
Blood urea:
1/1/23
2/1/23
X ray chest:
Platelets:
On 31/12/22-26000/mm3
1/1/23-22000/mm3
2/1/23-28000/mm3
3/1/23- 16000/mm3
4/1/23-26000/mm3
31/12/22. 1/1/23. 2/1/23
SGOT levels. 127. 123. 128
SGPT Levels. 62. 69. 67
Alkaline phosphatase. 682. 843. 915
Treatment:
IV fluids -Normal saline with 1 ampoule of optineuron
-Injection Noradr 2 ampoules in 46 ml NS
Inj PAN 40mgIV/OD
Tab PCM PO/TID
Inj Neomol .
3/01/23
S -
Decreased appetite
No fever spikes
Stools passed
O-
Pulse - 96 bpm
BP - 80/50 mmhg on norad 4ml/hr
RR - 32cpm
SPO2- 97 % AT RA
TEMP - AFEBRILE
CVS - S1 , S2 +
RS - BAE + , NVBS
PA - SOFT , NT.
NO ORGANOMEGALY
CNS - NAD
INPUT - 4850
OUTPUT-4300
HAEMOGRAM:
Hb – 9.7 gm/dl
TLC – 6700cells/cu mm
PLC - 16000
RENAL FUNCTION TESTS :
Sodium : 140 mEq/L
Potassium : 6.6 mEq/L
Chloride : 105mEq/L
A-
DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH AKI ( PRE RENAL -NON OLIGURIC) WITH ACUTE LIVER INJURY
P-
IVF - 1 NS With 1 Ampoule of optineuron 100 ml/hr
IVF Normal saline ,ringers lactate@ 150 ml /hour
Inj Noradr -2 ampoules in 46 ml NS @4 ml/hr
Inj Lasix 20 mg IV OD ( IF SBP >110 mmhg)
Tab Doxy 100 mg PO/BD
Monitor vitals 4th hrly
4/1/2023
S -
APPETITE IMPROVED
STOOLS PASSED
O-
PULSE - 96 bpm , regular
BP - 110/80 mmhg on norad 2ml/hr
RR - 32 CPM
SPO2- 96 % AT RA
TEMP - AFEBRILE
CVS - S1 , S2 +
RS - BAE + , NVBS
PA - SOFT , NT.
NO ORGANOMEGALY
CNS - NAD
INPUT - 3150 ml
OUTPUT-2900 ml
A-
DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH AKI ( PRE RENAL -NON OLIGURIC) WITH ACUTE LIVER INJURY
WITH HYPERKALEMIA
P-
IVF NS , RL ,DNS @ 100 ml /hour
INJ NORADR -2 ampoules IN 46 ml NS @2 ml/hr To taper according to MAP
TAB DOXY 100 mg PO/BD D3
MONITOR VITALS 4th HRLY in
5/1/2023
S -
APPETITE IMPROVED
O-
PULSE - 92 bpm
BP - 120/80 mmhg
RR - 28 CPM
SPO2- 98 % AT RA
TEMP - AFEBRILE
CVS - S1 , S2 +
RS - BAE + , NVBS
PA - SOFT , NT.
NO ORGANOMEGALY
CNS - NAD
INPUT - 2350
OUTPUT-2250
A-
DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH AKI ( PRE RENAL -NON OLIGURIC) -RESOLVED WITH ACUTE LIVER INJURY WITH HYPERKALEMIA (RESOLVED)
P-
IVF - 1 NS WITH 1 AMPOULE OF OPTINEURON @100ml/hr
IVF NS , RL ,DNS @ 100 ml /hour
TAB DOXY 100 mg PO/BD
2 EGG WHITES/DAY
MONITOR VITALS 4th HRLY
6/1/2023
S -
APPETITE IMPROVED
STOOLS NOT PASSED
O-
PULSE - 80 bpm
BP - 110/70 mmhg
RR - 24 CPM
SPO2- 98 % AT RA
TEMP - AFEBRILE
CVS - S1 , S2 +
RS - BAE + , NVBS
PA - SOFT , NT.
NO ORGANOMEGALY
CNS - NAD
INPUT - 2400
OUTPUT-2100
A-
DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH AKI ( PRE RENAL -NON OLIGURIC) -RESOLVED WITH ACUTE LIVER INJURY (RESOLVING)
P-
PLENTY OF ORAL FLUIDS
IVF - 1 NS WITH 1 AMPOULE OF OPTINEURON @50 ml/hr
IVF NS , RL ,DNS @ 50ml /hour
TAB DOXY 100 mg PO/BD D4
2 EGG WHITES/DAY
MONITOR VITALS 4th HRLY
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