dengue hemorrhagic fever with altered sensorium

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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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

Case report

50yr old female came to casualty with complaints of fever and cough since 7days 

breathlessness and abdominal diatention since 4days 

Altered sensorium since 4 days 

decreased urine output since 4days 

History of present illness

Patient was apparently asymptomatic 7days back then she developed fever and cough which were insidious in onset and gradually progressing, no aggrevating and relieving factors.

On day 3 she started having breathlessness and abdominal distention associated with Altered sensorium

Then she lost track ot what was happening around her

H/O decreased urine output since 4 days

Past history

No similar complaints in past 

She is a known case of diabetes 

No H/O hypertension, asthma, epilepsy, tuberculosis 

Personal history 

Diet mixed 

Appetite normal

Sleep inadequate 

Bowel and bladder regular

Occasionally drinks toddy

Family history 

No similar complaints in family 

Menstrual history 

Aom 12 years

Cycles regular

Menopause Attained

Obstetric history: nulliparous

General examination 

Patient is conscious coherent and cooperative 

Pallor -

Icterus +

Clubbing -

Cyanosis -

Koilonychia -

Lymphadenopathy -

Edema -

  On day 1

    on day 7

Vitals

Temperature 98.7 

Pulse rate 82 bpm 

Respiratory rate 22 cpm

Blood pressure 130/80

Spo2 98 % on RA

Systemic examination 

CNS

Level of consciousness: conscious coherent and cooperative 

Nomeningeal signs

Cranial nerves 

1) olfactory nerve ; percieves smell on both sides

2) optic nerve : normal visual acuity

3) occlomotor nerve ; normal

4) trochlear nerve ;  normal

6) abducens nerve ; normal

(3,4,6 cranial nerves) ; ptosis,squint, nystagmus - absent.

* Ocular movements- present in upward,downward,temporal,nasal gaze

* Pupil- size- normal,shape- central

* Visual reflexes- direct, indirect- reacting to light

5) Trigeminal nerve ; cutaneous sensibility over skin and mucous membranes - present

* corneal reflex- present on both sides

* deviation of jaw on opening mouth- absent

7) facial nerve; normal

8) vestibuli cochlear nerve; normal

9) glossopharyngeal nerve; Taste sensation on posterior 1/3rd of tongue - present on both sides

*palatal reflex- present on both sides

10)vagus nerve ; no history of regurgitation of fluids through nose

Palatal reflex- present

11) spinal accessory nerve ; normal

12) hypoglossal nerve ; normal

Motor system

Tone: normal in all limbs

Power: U/L.  L/L

RT.     4/5      4/5

LT.      4/5     4/5

Reflexes: B   T  S   K   A.  P

RT.         : ++ ++ +  ++  + Flexion

LT.          : ++  +  +  ++ + flexion

Pupil : reacting to light

Conjunctival reflex +

Corneal reflex+

Sensory system ; normal

No cerebellar signs

No meningeal signs

CVS

Inspection

Shape of chest; bilaterally symmetrical

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

Palpation

no palpable thrills,parasternal heaves are palpable

Auscultation; S1,S2 heart sounds are heared , no added murmurs,

Respiratory system 

Inspection of upper respiratory tract;

Nose; no DNS,polyp

Pharynx ; normal

Lower respiratory tract;

Position of trachea; midline

Symmetry of chest : symmetrical and elliptical

Movement of chest ; normal

 

Palpation 

Position of trachea,

No tenderness over chest wall,no crepitation s,no palpable added sounds,no palpable pleural rub

Percusion

Resonant note heared in all areas 

Auscultation

Normal vesicular breath sounds heard 

Bilateral air entry present 

Perabdominal examination 

inspection

Shape; distended due to fluid

Umbilicus; slightly retracted and inverted

Movements ; normal

No visible pulsations or engorged veins,no visible peristalsis

Skin over abdomen ;normal

Palpation

Abdomen is distended and soft

On palpation there is tenderness in Right hypochondrial region

Percussion 

Liver; dullnote heared,

shifting dullness+

No fluid thrills,

Auscultation

Bowel sounds are heared

Provisional diagnosis 

1.Dengue hemorrhagic fever 

2. Altered sensorium secondary to dengue encephalitis/hepatic/uremic encephalopathy 

3. With prerenal acute kidney injury 

4. Acute liver injury 

Investigations

   

                

                             2d echo

USG abdomen:

Grade-1 fatty liver

Edematous gallbladder wall

Moderate ascites

Treatment

1.Ivf normal saline
2.Ivf Ringer lactate
3.inj piptaz 2.25 gm iv tid
4.inj PAN 40 mg iv od
5.inj optineuron 1 ampule iv od
6.syp potklor 10 ml po tid
7.tab udiliv 300 mg po bd
8.syp lactulose 10 ml po bd