39 yr female with fever

September 16, 2022

September 9th

This is online E-blog, to discuss our patient de-identified health data shared after taking her 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 the patients clinical problem with current best evidence based input.This E-blog also reflects my patient's centred online learning portfolio.

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 come up with a diagnosis and treatment plan.

PRESENTING COMPLAINTS:

C/O Fever since 8 days.

C/O Generalized weakness for 6 days.

C/O SOB since a day.

C/O Loose stools for a day.

HOPI:

A 39 year female, Agriculturer by occupation clinically presented to casuality with complaints of High grade intermittent fever associated with chills and rigors, after a day she sought for consultation at a local RMP, she was started on IV fluids and sent home; On day 3 of fever she had severe frontal headache, for which she sought for consultation at local hospital and underwent treatment for typhoid fever for 5 days; during the course of hospital she still having high grade fever not associated with chills and rigors, generalized weakness for day 6 of fever; she was only on liquid diet during hospital stay. On day 7 of her fever she had an episode of loose stools, watery in consistency, non blood stained which was resolved on having medication and had shortness of breath of grade II NYHA for a day. The patient underwent routine work up, her Hb 8.6 gms%, TLC 11,600; Platelet 1.74lakhs/mm³; CRP 67 IU/L; WIDAL : O 1:160 ; H 1: 160 dilutions for S Typhi; Malaria test -ve; Dengue serology negative.

USG ABDOMEN done on 07/09/2022 showed findings s/o - Bilateral moderate pleural effusion; mild Ascites; Gall bladder wall edema. HRCT done on 07/09/2022 showed findings s/o - Bilateral Moderate pleural effusion; Atelectatic bands in bilateral lung fields predominantly in subpleural distribution; Moderate ascites. Patient and her attendee has been discharged as LAMA and sought for consultation and admitted now for further evaluation and management.

PAST ILLNESS:

No Comorbidities.

PERSONAL HISTORY:

Moderately built and nourished.

Appetite normal.

Decreased food intake because of nausea.

Bowel and bladder are regular.

Allergic to Dust.

No addictions.

FAMILY HISTORY:

No similar compalaints in the family.

MENSTRUAL HISTORY:

Age at Menarche: 15 yrs.

5/28 day cycle.

Menses were started on the day of admission at 5pm.

OBSTETRIC HISTORY

Age at 1st child birth : 19 yrs.

1st pregnancy: male child; spontaneous; Full term normal vaginal delivery + Episiotomy.

2nd pregnancy: female child; spontaneous; Full term normal vaginal delivery.

GENERAL EXAMINATION:

Patient was conscious and coherent.

Afebrile; Temp : 98.4°F.

PR: 84bpm; BP: 110/80mmHg; RR: 19cpm; SpO2: 98%@RA; GRBS: 97mg/dl.

CVS: S1,S2+; R/S: BAE+, Bilateral crepts at IAA; P/A: Soft, Non tender, BS+; CNS: NFND.

COURSE IN THE HOSPITAL:

A 39 year female presented with above mentioned complaints. Necessary investigations were done. Initial assessment was done. No postural drop, her BP on supine position was 110/60mmHg and standing was 110/70mmHg. A fever spike with a temp of 104.6°F was recorded in casuality and started her on IV Antipyretic. She has been shifted to ICU and handed over to ICU team. Her BP was 70/50mmHg and initial fluid resuscitation was done but the bp was not maintained to support the MAP. She was started on IV NORAD Infusion @5ml/hour. Her BP was 90/60 mmHg and complaining of an episode of loose stools. Her Hb was 10.4gm%; TLC 12700; platelet 210000 cells cu.mm. PT 14 sec; APTT 28 sec & INR 1.0. She had a fever spike of 100.6°F at 4 AM; and had complaints of nausea. Improvement in generalized weakness. On examination she had decreased breath sounds on ausculation at bilateral IAA & ISA; and dullness notes on percussion at bilateral IAA & ISA. Her BP was 90/70 mmHg on NA@1ml/hr; RR 32 cpm