55 F with fever, yellow discoloration of eyes and urine.

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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 come up with diagnosis and treatment plan.

A 55 year old female from narketpally came with chief complaints of
• Sweating ,generalised weakness, dizziness since morning 5.30.
• Fever, yellowish discoloration of urine and eyes since 20 days

HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 20 days back and then she developed fever which was intermittent (4 or 5 times since 20 days) and evening rise of temperature was seen for which she took paracetamol and it subsided .fever was not associated with chills and rigors.
She also had yellowish discoloration of eyes and urine since 20 days .
She also complains of burning micturition.

2 weeks back( on 1/7/22)  she came to our hospital and was asked to get admitted but due to financial problems their family denied it.
Treatment advised were- tab Udiliv 300mg BD,
MVT OD, Tab Dolo 650mg sos, continue antihypertensive and anti diabetic medications.
And then she took herbal medicines every monday for 2 weeks and stopped anti diabetic and anti hypertensive medications completely since 1 week(when she started taking herbal medications).
Today morning (18/7/22) at 2 AM she had difficulty passing urine and at  5.30 am she developed generalised weakness, dizziness and sweating and came at 6.30 am to Kims and got admitted.


PAST HISTORY
Known case of diabetes and hypertension since 5 years
Not a known case of asthma, tuberculosis, epilepsy.

PRESENT HISTORY
Daily routine :
She was an agricultural labourer by occupation.
She quit working since 5 years after she was diagnosed with diabetes and hypertension.

Wakes up at 6 AM
Does household work
Breakfast at 9 AM
Watches tv, cooking
Lunch at 1 PM
Sleeps, does some household work
Dinner at 8 PM
Sleeps at 9 PM

Diet: mixed
Appetite: normal
Bowel and bladder movements
     Yellowish urine, burning micturition.
     Difficulty passing stools
Sleep: adequate
Addictions : toddy but stopped 5 years ago.

TREATMENT HISTORY
Using Amlodipine for hypertension
And glimiperide, metformin for diabetes
Since 5 years

GENERAL EXAMINATION
Patient is conscious, coherent and cooperative.
Well oriented to time place person
Moderately built and moderately nourished

No pallor
Icterus present
No cyanosis
No clubbing
No lymphadenopathy
No edema

VITALS
PR: 84bpm
RR: 18cpm
TEMP :Afebrile
BP: 140/90mmhg
GRBS :on admission- 54mg%
          Afternoon-  162mg%
SP02 :99%


SYSTEMIC EXAMINATION
RS: BAE+, NVBS
CVS : S1 S2 heard, no murmurs
CNS: NFD
PA:
   Shape- obese
   No tenderness
   Umbilicus- normal
   Movements -moves with respiration
   No sinuses, distended veins
   Scar of hysterectomy 20yrs back
   No palpable mass
   Liver is palpable
   Spleen is not palpable
   Bowel sounds heard
   No bruits 

On 1/7/22

On 18/7/22

On 19/7/22

PROVISIONAL DIAGNOSIS

TOXIN INDUCED HEPATITIS


TREATMENT
1. Inj Pantop 40mg OD IV
2. Inj Zofer 4mg IV
3. Inj Neomol 1gm IV
4. Tab PCM 500mg BD
5. Tab Rifagut 550mg
6. Inj Trenexa 500mg IV stat
7. Tab Udiliv 300mg BD
8. Syrup Lactulose
9. Syrup Aristrozyme 25ml TID
10. Protein rich diet
11. Temperature charting ,GRBS monitoring .