Short case for final practical - 52 year old male with fever and abdominal tightness

 This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed.

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my cmpetancy i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

HALL TICKET NO - 1701006199

 A 52 year old male, resident of Nalgonda, farmer by occupation, came to hospital with the chief complaints of 

• Fever since 6 days
• Abdominal tightness since 6 days

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 6 days ago when he developed,

• Fever which was low grade and continuous, not associated with chills and rigor. No aggravating factor and relieved with medication given by local rmp doctor. 
• Abdominal tightness which was insidious in onset,not associated with pain ,vomiting and diarrhoea. 
• He also complaints of weakness since 6 days and decreased appetite since 5 days. 
• He was admitted into Nalgonda hospital for 2 days before getting admitted here he was diagnosed with thrombocytopenia with 17,000cells/mm³. 
• No history of headache,joint pains,body pains.
• No history of rashes and bleeding tendencies.
• No history of weight loss.

PAST HISTORY:

• No similar complaints in the past.
• No history of diabetes mellitus, hypertension, tuberculosis, asthma and epilepsy.

PERSONAL HISTORY:

• Diet - Mixed.
• Appetite- decreased since 5 days.
• Sleep - adequate.
• Bowel and bladder- regular.
• Addictions: consumes Alcohol and toddy since 15 years.

FAMILY HISTORY:

No similar complaints.

GENERAL EXAMINATION:

Patient was examined in a well lit room after taking informed consent. 

He is conscious, coherent and cooperative; moderately built and well nourished.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS:

• Pulse - 90 beats per minutee
• Respiratory rate - 20 cycles per minute.
• Temperature - afebrile.
• Blood pressure - 120/80 mmHg.
• Spo2 - 98%.
• GRBS - 110 mg/dl.

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION:

• INSPECTION:

Abdomen shape - distended

Flanks full

Umbilicus - normal

No visible scars, sinuses , striae , engorged veins.

No visible gastric peristalsis.

• PALPATION:

No local rise of temperature.

No tenderness.

Abdomen distended.

Organs not palpable

• PERCUSSION: Fluid thrill is present.

• AUSCULTATION: 

Normal bowel sounds heard.

No bruit.

RESPIRATORY EXAMINATION:

• BAE Present.
• Normal vesicular breath sounds heard.

CVS EXAMINATION: 

• S1 S2 Heard, no murmurs.

CNS EXAMINATION: 

• No neurological deficit.

INVESTIGATIONS:

8/06/2022

 Blood urea - 59 mg/dl

 Serum creatinine - 1.6mg/dl

Serum electrolytes:

• Na - 142 mEq/l
• K- 3.9mEq/l
• Cl - 103 mEq/l

Liver function tests-

• Total bilirubin - 1.27 mg/dl
• Direct bilirubin - 0.44 mg/dl
• AST - 60 IU/L
• ALT - 47 IU/L
• ALP - 127IU/L
• Total proteins - 5.9 gm/dl
• Albumin - 3.5g/dl
• A/G ratio - 1.48

Complete urine examination:

• Albumin - 2+
• Pus cells - 4-6
• Epithelial cells - 2 -3.

NS1 ANTIGEN Test - Positive.

IgM and IgG - Negative.

HIV RAPID TEST - Non reactive.

HBsAg Rapid test - Negative.

Anti HCV antibodies - Non reactive.

Ultrasound - Mild splenomegaly .

On right side mild pleural effusion.

Mild ascites.

Grade 2 fatty liver.

Gall bladder wall - edematous.

Hemogram:

On 08-06-22, 

Hemoglobin - 14.9 gm/dl.

Total leucocyte count- 10,500cells/ mm³.

Neutrophils- 43%

Lymphocytes- 48%.

Eosinophils - 01%.

Platelet count - 22000 cells/ cumm.

PCV - 42.2

On 09-06-22,

Hemoglobin: 14.3gm/dl.

Wbc - 8200 cells/cumm

Neutrophils - 38%

Lymphocytes-51%.

Platelet count - 30,000/cumm.

PCV - 42.0

On 10-06-22,

Hemoglobin- 14 gm/ dl 

Tlc - 5680cells/cumm.

Neutrophils -35%

Lymphocytes - 54%.

Platelet count-84,000/cumm.

On 11-06-22,

Wbc- 4800 cells/cumm.

Neutrophils - 40%

Lymphocytes-48%

Platelet count -60,000cells/cumm

Platelet count -76000cell/cumm.(Same day evening)

On 12-06-22, 

Hb-15.3

Wbc - 7,100.

Neutrophils - 40%

Lympocytes -50%

Platelet count- 1 lakhcells/cumm.

PCV - 44.6

PROVISIONAL DIAGNOSIS:

Viral pyrexia with thrombocytopenia secondary to dengue NS1 POSITIVE with polyserositis.

TREATMENT:

12-06-22

• IV infusion NS/RL/DNS continuous at 100ml/hr
• Inj. PAN 40mg IV BD 
• Inj. ZOFER 4mg IV/SOS
• Inj. NEOMOL 1gm IV/SOS
• Tab. PCM 650 mg PO/ SOS
• Inj. OPTINEURON 1 Ampoule in 100ml NS IV/OD over 30mins.

13-06-22

• Oral Fluids
• Tab. DOLO 650mg PO SOS
• Tab. PAN 10mg PO OD
• Tab. DOXYCYCLINE 100mg PO BD
• Tab. ZINCOVIT PO OD
• Vitals monitoring.