50yr female with dengue complicated with ascites

A 50yr old female with fever, abdominal distention and shortness of breath. 

Date: 3/3/22

Name- K. Medha Reddy
Roll.no- 51
Batch-2017



This is an online E-log book to discuss our patient de-identified health data shared after taking his/ her guardians sign 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 clinical problem with collective current best evidence based inputs.


This E-log also reflects my patient centered online learning portfolio.

Your valuable inputs on comment box is welcome

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



CASE:


A 50 yr old female came to the hospital on Wednesday (2/3/22) with chief complaints of :

• Fever since 4days
• Abdominal distention since 4 days 
• Burning micturition since 2 days


HOPI:
• Patient was apparently assymptomatic 13 yrs ago, then she was diagnosed with Tuberculosis along with HIV. She took medications for TB and is on ART for HIV.
• She developed hypopigmented patches on her arms,trunk and face for which she took medications. 
• 1 month ago, she felt that her abdomen was distended. 
• 4 days ago, she developed fever, which increased at night, not associated with chills and rigor. 
• She also complained of distention of abdomen which increased in size from 4 days.
• Shortness of breath since 4 days. 
• She had history of 2 episodes of vomitings 1 day ago, non bilious with food as it's contents.


Negative history:
No H/O cold and cough
No retro orbital pain
No H/O any other pain 

PAST HISTORY:
H/O hypopigmented patches due to HIV 10yrs ago.
Not a k/c/o DM/HTN/Epilepsy/Asthma/TB/CAD/ CVA

PERSONAL HISTORY:
Diet : mixed
Appetite : Decreased
Sleep : Decreased
Bowel habits : constipation since 2 days
Bladder habits : burning micturition since 2 days
Menstrual History : Menopause attained 8yrs ago

FAMILY HISTORY : Insignificant

GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative and was examined in a well lit room with informed consent. 

VITALS:
Temperature : Aferbile (currently 98.8°F)
PR : 100bpm
RR : 18cpm
BP : 110/90 mmHg
SPO2 : 96%
JVP : not seen

No Pallor, icterus, cyanosis, clubbing, lymphadenopathy, peadal edema.

SYSTEMIC EXAMINATION:

CNS : 
Higher and lower motor functions normal
Sensory system is intact

CVS : 
S1, S2 heard
No added murmurs

RS : 
NVBS heard
Bilateral Air entry present.
W.r.t SOB, present at rest

P/A : 

INSPECTION:
Distention of Abdomen is seen
Umbilicus is inverted
Petechiae in the right hypochindriac region.


PALPATION: 
Hepatomegaly could be felt.
Fluid thrill is ABSENT 
No splenomegaly

PERCUSSION: 
Shifting dullness is seen. 
A dull note is heard in the Left lumbar region and a resonant note is heard in the umbilical region.

AUSCULTATION: 
Normal bowel sounds heard.

INVESTIGATIONS:
 
HEMOGRAM: 
HB : 13.8
TLC : 3,700
N/L/E/M/B : 45/46/01/08/00
PCV : 40.9
MCV : 109.5
MCH : 36.9
MCHC : 33.7
RBC : 3.74
PT : 8000
RDW-CV : 13.5
RDW-SD : 56.2
PS : NC/NC

BLOOD UREA: 39
BUN: 18.2

LFT: 
TB: 0.82
DB: 0.20
AST: 676
ALT: 265
ALP: 754
TP: 5.4
A: 3.2
A/G : 1.51

CUE: 
A: +
sugar: nil
PC: 3-4

RFT:
Serum creatinine: 1.1
Na+2 : 141
K+ : 3.8
Cl : 107
UA : 6.5

ECG:
USG:
2D ECHO:
X-RAY:
FEVER CHART:

PROVISIONAL DIAGNOSIS : 
Dengue NS1 antigen positive

TREATMENT : 
ivf - NS and RL @ 100ml/hr
Inj. Pantop 40 mg/iv/od
Inj. Zofer 4 mg/iv/sos
Inj. Neomal 100ml ( if temp > 101.1.f) iv/sos
Tab. Mvt /po/od
Fever charting hourly 
Bun,plv daily

SOAP NOTES:
Amc
Day 2 (4/3/22)
Bed no : 3
50y/F

S: 
shortness of breath (grade - 2 ) 
Petechiae + on abdomen 
1 pack of SDP transfusion done yesterday 

O:
O/E:
Patient is c/c/c
Temp : Afebrile
PR : 97bpm , regular, low volume
RR : 17cpm
BP : 110/80 mmhg
Spo2 : 97% at RA
Cvs : S1 S2 +, no murmurs
RS : Decreased breath sounds in right ISA , IAA
PA : distended , bowel sounds+
GRBS : 114mg/dl

A : 
Dengue NS1 antigen positive with k/c/o , HIV + with right sided pleural effusion 

P:
1.Ivf - 1 Ns , 1 Rl @ 150ml / hour with 1 amp of optineurin
2.inj pan 40mg/iv/od
3.inj zofer 4mg/iv/sos
4.inj neomol 100ml /iv/ if temp > 101.1°F
5.tab.pcm 500mg/po/bd
6.pcv and bun daily 
7.Monitor vitals 4th hrly
8.check for bleeding manifestations


Amc Bed 3
Day 3 (5/3/22)
50y/F

S :
shortness of breath (grade - 2 ) 
Petechiae + on abdomen 
CD4 - 585 (21/12/21)

O:
O/E:
Patient is c/c/c
Temp : Afebrile
PR : 100bpm , regular, low volume
RR : 17cpm
BP: 110/80 mmhg
Spo2 : 97% at RA
Cvs : S1 S2 +, no murmurs
Rs : Decreased breath sounds in right ISA , IAA
PA : distended , hepatomegaly+ , liver - 14cm , bowel sounds +
Grbs : 96mg/dl

A : 
dengue NS1 antigen positive with k/c/o , HIV + with right sided pleural effusion 

P:
1.Ivf - 1 Ns , 1 Rl @ 150ml / hour with 1 amp of optineurin
2.inj pan 40mg/iv/od
3.inj zofer 4mg/iv/sos
4.inj neomol 100ml /iv/ if temp > 101.1°F
5.tab.pcm 500mg/po/bd
6.pcv and bun daily 
7.Monitor vitals 4th hrly
8.check for bleeding manifestations


REVIEW USG:


DERMATOLOGY REFFERAL: 
For the hypopigmented patches


Amc Bed 3
Day 4
50y/F

S: no fever spikes 

O:
O/e
Patient is c/c/c
Temp : Afebrile
PR : 97bpm , regular, low volume
RR : 17cpm
BP : 110/80 mmhg
Spo2 : 97% at RA
Cvs : S1 S2 +, no murmurs
RS : NVBS +
        Decreased breath sounds in right isa, msa
PA : soft, distended, bowel sounds +, hepatomegaly +

A : dengue NS1 antigen positive with k/c/o HIV + since 13 years with right sided pleural effusion with borderline tuberculoid leprosy ? Type 1 reaction 

P:
1.Plenty of oral fluids
2.inj pan 40mg/iv/od
3.inj zofer 4mg/iv/sos
4.inj neomol 100ml /iv/ if temp > 101.1°F
5.tab.pcm 500mg/po/bd
6.pcv and bun daily 
7.Monitor vitals 4th hrly
8.check for bleeding manifestations
9.liquid paraffin L/A bd

Review ECG:
Fever chart update: 
Ward
Day 5
50y/F

S: no fever spikes 

O:
O/e
Patient is c/c/c
Temp:Afebrile
PR : 97bpm , regular, low volume
RR : 17cpm
BP : 110/80 mmhg
Spo2 : 97% at RA
Cvs : S1 S2 +, no murmurs
RS : NVBS + , decreased breath sounds in right isa, msa
PA: soft , distended , bowel sounds+ , hepatomegaly+

A : dengue NS1 antigen positive with k/c/o HIV + since 13 years with right sided pleural effusion with borderline tuberculoid leprosy ? Type 1 reaction 

P:
1.Plenty of oral fluids
2.inj pan 40mg/iv/od
3.inj zofer 4mg/iv/sos
4.inj neomol 100ml /iv/ if temp > 101.1°F
5.tab.pcm 500mg/po/bd
6.pcv and bun daily 
7.Monitor vitals 4th hrly
8.check for bleeding manifestations
9.liquid paraffin L/A bd

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