50yr old female with abdominal distention and altered sensorium

 

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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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

Case report

50yr old female came to casualty with complaints of fever since 7\days 

C/o dry cough since 7 days 

C/o breathlessness since 4days 

C/o abdominal distension since 4days 

C/o decreased urine output since 4days 

History of present illness

  she was apparently alright 7days ago then she developed fever associated with chills insidious in onset, not associated with myalgia or arthralgia 

H/o dry cough since 7days , no seasonal variation or diurnal variation , not associated with blood, fever associated with decrease in appetite 

On day 3 of illness, she was having c/o breathlessness gradually progressive from grade 2

H/o abdominal distension since 4days gradually progressive to present size associated with abdominal pain 

H/o decreased urinary output since 4days 

No hematuria, blood in stools or other bleeding manifestations complaints 

Past history

No similar complaints in past 

She is a known case of diabetes 

No H/O hypertension, asthma, epilepsy, tuberculosis 

Personal history :

Appetite: decreased

Diet: mixed

Bowel and bladder: regular

Sleep: adequate

Addictions: occasional alcoholic and toddy drinker

Menstrual history:

Age of menarch: 12 years

Cycles regular

Attained menopause

Obstretric history: nulliparous

Family history: insignificant

General examination :

Patient was conscious coherent and cooperative

pallor : present

Icterus: present

Cyanosis -

Clubbing-

Lymphadenopathy -

Edema. -

Local examination on

there is no petechiae

ONVn admission

Petechiae seen on arm and fore arm 

Vitals

Temperature 98.7 

Pulse rate 82 bpm 

Respiratory rate 22 cpm

Blood pressure 130/80

Spo2 98 % on RA

Today 

CVS

Inspection

Shape of chest; bilaterally symmetrical

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

Palpation

no palpable thrills,parasternal heaves are palpable

Auscultation; S1,S2 heart sounds are heared , no added murmurs,

Respiratory system 

Lower respiratory tract;

Position of trachea; midline

Symmetry of chest : symmetrical and elliptical

Movement of chest ; normal

 

Palpation 

Position of trachea,

No tenderness over chest wall,no crepitation s,no palpable added sounds,no palpable pleural rub

Percusion

Resonant note heared in all areas 

Auscultation

Normal vesicular breath sounds heard 

Bilateral air entry present 

Perabdominal examination 

inspection

Shape; distended due to fluid

Umbilicus; slightly retracted and inverted

Movements ; normal

No visible pulsations or engorged veins,no visible peristalsis

Skin over abdomen ;normal\

Palpation

Abdomen is distended and soft

On palpation there is tenderness in Right hypochondrial region

Percussion 

Liver; dullnote heared,

shifting dullness+

No fluid thrills

,

Auscultation

Bowel sounds are heared

Provisional diagnosis 

1.Dengue hemorrhagic fever 

2. Altered sensorium secondary to dengue encephalitis/hepatic/ uremic encephalopathy 

3. With prerenal acute kidney injury 

4. Acute liver injury 

Investigations

USG abdomen:

Grade-1 fatty liver

Edematous gallbladder wall

Moderate ascites

   

 Treatment 

 Iv fluids @ 100ml/hr

Inj piptaz 2.25 gm/iv/Tid- d3

Inj optineuron 1 ampoule in 100ml nd iv /od

T.doxy 100mg/RT/BD converted to oral 

Tab. Udiliv 300mg po bd

Tab pltkor 10 ml po bd 

Syp lactulose 10 ml bd

Discussion