55 year old female with DSS

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I’ve 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 .

CHIEF COMPLAINTS: 

Fever since 10 days

Generalised weakness since 10 days

HOPI :

Patient was apparently asymptomatic 10 days back, then she developed fever which is of high grade , intermittent, associated with chills and rigor, no diurnal variation and relieved with medication. 

Generalised weakness and fatigue since 8 days.

SOB since 6 days which is insidious in onset , gradually progressive to grade 2.

Pedal edema since 5 days , pitting type , extending till knee.

Got admitted at outside hospital and was treated with chloroquine and ceftriaxone but symptoms are not subsided

No H/O cold , cough , vomitings, loose stools 

PAST HISTORY:

Not a k/c/o DM , HTN , epilepsy, asthma , CAD , CVD,TB

PERSONAL HISTORY:

Appetite-Decreased 

Diet - Mixed

Bowel and bladder - regular 

Sleep - Decreased.

General examination:

Patient is conscious, coherent, cooperative, well oriented to time , place and person 

Pallor - present 

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy- absent 

Pedal edema - pitting type extending till knee 

VITALS :  Temp - 98.6 F

                  PR - 62 bpm

                 BP - 80/50 mmhg

                RR - 32 cpm

                SPO2 - 98% onRA

                GRBS - 102 mg/dl

Systemic examination: 

PER ABDOMEN:

Inspection :

Umbilicus is central and inverted

      All quadrants are moving equally with respiration 

          No scars , sinuses , engorged veins, visible pulsations .

          Hernial orifices are free.

Palpitation :

          Abdomen is soft and mild tenderloin in right hypochondrium.

          No organomegaly.

Percussion :

         Tympanic note heard over the abdomen.

Auscultation:

          Bowel sounds are heard.

CARDIOVASCULAR SYSTEM:

Inspection:

        Shape of chest is elliptical.

        No raised JVP

        No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

        Apex beat - felt at left 5th intercostal space

        No thrills and parasternal heaves

Auscultation :

        S1 and S2 heard. 

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes    Right    Left

Biceps         ++         ++

Triceps        ++         ++

Supinator    ++       ++

Knee            ++       ++

Ankle           ++        ++

Investigations :

On day of admission-

CBP :

         Hb – 9.1 gm/dl

         TLC – 5000cells/cu mm

         Neutrophils : 65

         Lymohocytes : 32

         Eosinophils : 00

         Monocytes : 03

         Platelets – 26000/cu mm

CUE :

         Albumin - traces 

         Pus cells - 2-3/HPF

         Epithelial cells - 2-3/HPF

RENAL FUNCTION TESTS :

          Urea : 117 mg/dl

         Creatinine : 1.9 mg/dl

         Sodium : 136 mEq/L

         Potassium : 3.9 mEq/L

         Chloride : 106 mEq/L

LIVER FUNCTION TESTS :

         Total bilirubin : 2.93 mg/dl

           Direct bilirubin : 1.28 mg/dl

           AST : 127 IU/L

           ALT : 62 IU/L

           Alkaline phosphate :682 IU/L

           Total proteins : 4.9 gm/dl

           Albumin : 2.0 gm/dl

           A/G ratio :  0.71

DENGUE:

NS1 - Negative 

IgM- Positive 

IgG - Negative 

TPR CHART:

CHEST X RAY:

ECG :

On 31/12/22:

On 4/1/23:

On 6/1/23:

USG : 

TREATMENT:

Inj OPTINEURON in 100 ml NS

IVF NS,RL,DNS @ 100ml/hr

Inj NORAD 2 ampoules in 46 ml NS

Tab DOXYCYCLINE 100 mg po/bd

Tab Dolo 650 mg po/sos

Inj LASIX 20 mg (if  SBP >120/80 )

Monitor vitals

PROVISIONAL DIAGNOSIS:

DENGUE SHOCK SYNDROME WITH THROMBOCYTOPENIA WITH ACUTE KIDNEY INJURY WITH ACUTE LIVER INJURY.