1801006032 LONG CASE

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

55years old female came to OPD with 

chief complaints of 

1) Fever since 14 days 

2) Abdominal pain since 10 days,

3) shortness of breath since 10 days

4) vomitings since 3 days

History of present illness 

Patient was apparently asymptomatic 14 days back then she developed Fever, which is insidious in onset, low grade , intermittent, associated with chills and rigor with no aggrevating factors and relieved on medication on first 2 days

then she developed Abdominal pain since 10 days,which is insidious in onset, gradually progressive, she localised the pain to her right upper quadrant, it was sharp in nature and not radiating ,no aggregating factors ,relieved temporarily on medication

then she developed shortness of breath, since 10 days,which is insidious onset, which is grade 2 (NYHA classification) - slight limitation of activity -ordinary activity results in fatigue) ,no aggrevating and no relieving factors and not associated with orthopnea and paroxysmal nocturnal dyspnea 

She had history of vomitings prior to the day joining in the hospital which is of 2 episodes, watery in consistency ,non projectile,non bile stained,non foul smelling and non blood stained 

Associated with generalized weakness and decreased urine output since from the day prior to the hospitalization 

No history of trauma 

Timeline of illness:

Patient was normal 14 days back then she developed fever for which she went RMP doctor, medication was given and symptoms got subsided

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after 3 days she developed abdominal pain which is sudden and severe for which she went to hospital and diagnosed as AKI she given medication for 5 days and symptomatic relief present 

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then on 13/3/23 she developed generalized weakness, shortness of breath,abdominal pain,vomitings which led to hospitalization 

Past history 

She diagnosed with hypertension since 1year for which she taking medication (telma H)

No history of diabetes mellitus, tuberculosis, asthma, thyroid, epilepsy 

No history of previous surgeries and no previous hospitalization

 

Family history:

No significant family history

Personal history:

Daily routine activities:

She usually wakeup at 6 AM, completes her regular activities in an hour

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Around 8 AM she takes her breakfast (rice and vegetables curry) and goes to market as she sell lemons from past 20 years

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 and lunch at 1 PM and came to home at 5PM and takes a cup of tea and

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 she takes dinner at 9 PM 

(She has an habit of taking alcohol around 10-20 ml,while going to bed) once in 3 days since 15 years) 

Diet: mixed

Sleep: reduced since 10days

Bowel movement: regular

Bladder movement: reduced since 10days

Addiction: (She has an habit of taking alcohol around 10-20 ml,while going to bed) once in 3 days since 15 years) 

General examination: patient is conscious, coherent, cooperative well oriented with time ,place, person

Moderately nourished and moderately built

Pallor: mild 

Icterus: mild

Cyanosis: absent

Clubbing: absent

Lymphadenopathy: absent

Edema: absent

Vitals:

Pulse rate: 80bpm

Blood pressure: 140/80 

Respiratory rate: 26 cycles per minute

Temperature:

Fever chart:

Systemic examination:

Abdominal examination:

INSPECTION:

Shape round (generalized distension)

Umbilicus - slightly retracted and inverted (normal)

Equal symmetrical movements in all the quadrants with respiration.

No visible pulsation, peristalsis, dilated veins and localized swellings.

PALPATION:

SUPERFICIAL : local rise of temperature and tenderness in right hypochondrium, epigastrium

DEEP : enlarged liver, extent upto 4cm below the costal margin,(confirmed by percussion)

Rounded edges soft in consistency, tender, moving with respiration non pulsatile, 

No splenomegaly 

Abdominal girth : 105cm

Xiphisterum to umbilicus:22cm (indicates umbilicus displaced downwards due to hepatosplenomegaly)

Umbilicus to pubic symphysis:14cm

PERCUSSION:

Hepatomegaly,liver span of 14cm with 4cm extended below the costal margin

Fluid thrill and shifting dullness absent 

puddle sign absent

AUSCULTATION:

Bowel sounds are heard

RESPIRATORY SYSTEM:

Trachea central

Bilateral air entry

Normal vesicular breath sounds present

CENTRAL NERVOUS SYSTEM:

No focal neurological deficit

CARDIOVASCULAR SYSTEM:

S1,S2 sounds heard,no murmur are seen 

DD:

Viral hepatitis?

Cholecystitis?

Alcoholic hepatitis?

Sepsis?

INVESTIGATIONS:

1) USG abdomen:

Findings- 5 mm calculus noted in gall bladder with GB sludge

Impression- Cholithiasis with GB sludge

Grade 2 fatty liver with hepatomegaly 

2)Renal Function Tests:

13th

Blood urea 58

Serum creatinine 1.9

serum Na 127

Serum K 3.4

Serum Cl 92

14th

Blood urea 64

Serum creatinine 2.1

serum Na 117

Serum K 3.4

Serum Cl 70

15th

Blood urea 64

Serum creatinine 1.6

serum Na 125

Serum K 3.0

Serum Cl 88

3)LIVER FUNCTION TEST:

14th 

Total bilirubin:2.6*

Direct bilirubin: 1.1*

Indirect bilirubin:1.5*

Alkaline phosphatase:193*

AST:37

ALT:21

Protein total: 7.0

Albumin:4.3

Globulin:2.7

Albumin and globulin ratio:1.6

4)Complete Urine Examination:

Albumin:+ 

Sugar: nil

pus cells:3-6

epithelial cells-2-4

urinary na 116

urinary k 8

urinary cl 128

5) Arterial blood gas:

Pco2: 23.3

PH: 7.525

Hco3: 23

Po2: 80.8

6) x ray Abdomen

7) complete blood picture:

13-3-23 

Haemoglobin:11.7

Red blood cells:3.81

Pcv:32.5

Platelet count:5.0

Total leucocyte count:22,400

8)ECG:

9)lipid profile:

Total cholesterol:218mg/dl

Triglycerides:240mg/dl

HDL cholestrol:54 mg/dl

LDL cholestrol:116mg/dl

VLDL Cholestrol:48mg/dl

10)dengue 

Ns1antigen test negative

11) thyroid function test:

T3:0.33

T4:10.46

Tsh:3.30

On 15/3/23/

Total leucocyte count:26,000

Serum calcium:0.92

PROVISIONAL DIAGNOSIS:

Non Alcoholic steatohepatitis 

AKI secondary to sepsis(?)

Cholelithiasis 

TREATMENT PLAN:

Liquid diet

1. Iv fluids 1 unit NS, RL, DNS 100 ml/hr

2. Inj PAN 40 mg iv/ od

3. Inj PIPTAZ 2.25mg/iv/TID

4. Inj. METROGYL 500mg / iv/tid

5. Inj zofer 4mg iv/sos

6.INJ NEOMOL 1gm iv/sos

7.T.PCM 650mg po/tid

8.T.CINOD 10mg po/od