Fever under evaluation, anemia under evaluation( ?secondary to blood loss)





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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."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 a diagnosis and treatment plan 


PYREXIA UNDER EVALUATION [PUO] ASCITES SECONDARY TO CHRONIC LIVER DISEASE [HIGH SAAG LOW PROTIEN]  

57 YEAR OLD FEMALE PRESENTED TO THE CAUSALITY WITH CHEIF COMPLAINTS OF  LOSS OF APPETITE SINCE 2 MONTHS AND FEVER SINCE 20 DAYS
PT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS BACK THEN SHE DEVELOPED FEVER WITH CHILLS  AND GOT ADMITTED IN OUR HOSPITAL ON 26/12/22

NOW PATIENT CAME TO HOSPITAL WITH COMPLAINTS OF LOSS OF APPETITE SINCE 2 MONTHS AND FEVER OF 2 EPISODES IN PAST 20 DAYS
FEVER IS INSIDIOUDS IN ONSET ,HIGH GRADE , ASSOCIATED WITH CHILLS AND RIGORS  AND RELIEVED BY TAKING MEDICATION

NO SOB , GRADE 2 RELIEVED BY TAKING REST , PEDAL EDEMA PRESENT TILL KNEE NO DECREASED URINE OUTPUT, NO BURNING MICTURITION  

K/C/O EPILEPSY SINCE 4 YEARS ON T. PHENYTOIN 100MG 
K/C/O HTN SINCE 4 YEARS AND ON T. AMLODIPINE 10MG
K/C/O HYPOTHYROIDISM SINCE 4 YEARS AND ON T.LEVOTHYROXINE 25MCG
DIAGNOSED AS DENOVO TYPE 2 DM BUT NOT ON ANY MEDICATION
N/K/C/O CAD ASTHAMA OR TB
 
GENERAL EXAMINATION - PT IS C/C/C/
 PALLOR PRESENT
NO ICTERUS , CYANOSIS , CLUBBING , LYMPHADENOPATHY , EDEMA
AT PRESENTATION                           AT DISCHARGE 
TEMP - 99.1F                                      TEMP:AFEBRILE
BP - 120/80MMHG                               BP:130/80MMHG
PR - 110BPM                                       PR:92BPM
RR - 18CPM                                        RR:18CPM
SPO2 -99 ON ROOM AIR                              GRBS:116MG/DL                                 GRBS - 145 MG/DL






SYSTEMIC EXAMINATION -

RESPIRATORY SYSTEM -BAE PRESENT NVBS

CVS - S1S2 HEARD , NO MURMURS

CNS - HMF INTACT , NFND

P/A - SOFT ,NON TENDER, NO RIGIDITY ,NO GUARDING, DISTENDED UMBLICUS EVERTED
SHIFTING DULLNES PRESENT 
FLUID TRILL ABSENT
 
GASTROENTEROLOGY OPINION WAS TAKEN I/V/O GROSS ASCITES WITH CHRONIC LIVER DISEASE WITH MILD HEPATOSPLENOMEGALY
AND WAS ASKED TO REVISIT WITH ANA WITH TITRE , ANTI SMOOTH MUSCLE ANTIBODY,AFP AND DOPPLER STUDY OF RENAL VEINS REPORTS 

BLOOD TRANSFUSION WAS DONE ON 22/2/23 I/V/O LOW HEMOGLOBIN LEVELS

INVESTIONS:

















USG ABDOMEN - E/O IRREGULAR SURFACE WITH COARSE ECHOTEXTURE OF LIVER
PV-13-14MM WITH FEW PERIPORTAL COLLATERALS AT THE HEAD OF PANCREAS 
MILD HEPATOSPLENOMEGALY
GROSS ASCITES
S/O CHRONIC LIVER DISEASE
RAISED ECHOTEXTURE OF BOTH KIDNEYS 

TREATMENT :
FLUID RESTRICTION UNDER 2L/DAY
SALT RESTRICTION UNDER 2GM/DAY
INJ LASIX 40MG IV/BD
T.ALDACTONE 25MG PO/OD
T.PCM 650MG PO/SOS
T.LEVOTHYROXINE 25MCG PO/OD
T.PHENYTOIN 100MG PO/OD
T.ECOSPIRIN AV 75/2O PO/HS
T.AMLODIPINE 10MG PO/OD
SYP.LACTULOSE 30ML PO/HS
PROTIEN POWDER 2 TABLE SPOONS IN 100ML MILK/BD
ABDOMINAL GIRTH AND WEIGHT MONITORING


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