CASE PRESENTATION

Presented by
Dr. Tanzina shabrin

On behalf of,
Department of medicine
Dhaka central international medical college.
PARTICULARS OF THE PATIENT
Name : Mr. Abdul Aziz
Age : 79 years
Sex : Male
Occupation : Ex- Railway worker
Address : College road, Ishardi, Pabna.
PRESENTING COMPLAINT
• Fever with rash for 13 days
• Abdominal pain with distended abdomen for 10 days

what may be the possibilities?

HISTORY OF PRESENT ILLNESS
• According to the patient’s statement,he was reasonably well 13 days back.
Then he developed fever. Fever was continuous in nature intially,later it
becomes intermittent. Highest recorded temperature was 103 deg F. Fever
was subsided with paracetamol.

• He also developed rash which begins 3rd or 4th day of fever. It was small,
macular red in nature. Rash initially starts on the abdomen,chest and later
on the hand and back.Rash was not itchy and it was painless in nature.

• He also mentioned he had abdominal pain for 10 days.In the beginning, it

was on the whole abdomen then subsided and persist on the right
hypochondrium region. pain was aggravated by taking food. Pain was not
radiating. It relieved by taking medication.( Tiemonium Methylsulphate) .
 Contd….
• He complains of anorexia,nausea and weakness.
• He also mentioned, he fell 2 times during high grade fever but
had no history of seizure, and did not loss of consciousness.

• He is normotensive and diabetic for 8 years,his diabetic status

was in under control. But during fever his RBS was 15.9 mmol/l

• After admission in the hospital, he developed pitting bipedal

edema.

• He has no history of ascites,chest pain and breathlessness.

Contd..
• He was a diagnosed case of mild BEP.

• He mentioned, sometimes he has frequency of urine,

which persist 3 to 4 days,dark in colour. But he has no
burning sensation of micturition or any other urinary
symptoms.

• He also mentioned he had constipation for last 3 to 5

days.His bowel and bladder habit was normal before.

• He has no history of weight-loss, joint pain or

headache.
Past History
• He has diabetes mellitus for 8 years.
• He has mild BEP.
Drug history:
He took ceftriaxone 2gm for 7 days, Mirabegron,
Sitagliptin M, Glimepiride, Dexlansoprazol and some
paracetamol.
PERSONAL HISTORY
• He has no history of smoking ,alcohol and betel-nut chewing
• Non drug-abuser.
FAMILY HISTORY
• Nothing significant.
SOCIO-ECONOMIC HISTORY
• He belongs to higher middle-class family.
Travelling History:
• Nothing significant
Immunization history
• He is duly immunized according to EPI schedule
• He has taken full course of covid - 19 vaccine.
What will be the focus of
examination ?
 General
examination
• Appearance : Ill looking
• Body built : Average
• Anaemia : Absent
• Jaundice : Mild
• Leukonychia : Absent
• koilonychia : Absent
• Clubbing : present
Cont..
• Dehydration : Absent
• Thyroid gland : Not
enlarged
• Lymph node : Not palpable
• Jvp : Not raised
• oedema : Present
(bipedal,pitting)
Cont..
• Vitals
• Pulse : 80 beat/min
• Blood Pressure : 110/70 mmHg
• Temperature : 100 degF
• Respiratory : 16 breath /min
Systemic Examination:
Abdominal examination
• Inspection : Abdomen is distended,umbilicus is
inverted,there is no scar mark,peristalsis,and visible
pulsation.
Palpation : There is abdominal tenderness on deep palpation.
• Any organ or mass not palpable.
• upper border of liver dullness in 5th intercostal space in the mid
clavicular line. There is no fluid thrill or shifting dullness.

• Percussion : Percussion note is tympenic.

• Auscultation : Bowel sound present.

Nervous system examination :

• Higher psychic function : normal

• Motor function examination:
• Bulk of muscle : normal
• Tone of muscle : normal
• Power of muscle : normal
• Reflexes : normal
• Co-ordination of movement :normal
• Gait : normal
Cont..

• Sensory examination (touch,pain,temperature,vibration) is

normal.
• Cranial nerves examination is normal.
• There is no sign of meningeal irritation.
Other systems reveal no abnormalities.
Salient Feature:
• Mr.Abdul Aziz,79 years old, Male ,Ex- railway station worker ,hailing
from Ishardi ,Pabna. He admitted to this hospital on 23rd august with
the complains of Fever with Rash for 13 days and abdominal pain for
10 days.Highest recorded temperature was 103 deg f. Fever subsided
with paracetamol. After3 to 4 days he developed rash which was
macular in nature and it was not itchy and painless.
• He also mentioned of abdominal pain for 10 days and subsided with
medication but persist on right hypochondrium region.pain was not
radiating and it aggravated by food.
• He also complains of anorexia,nausea and weakness. He mentioned,
he fell 2 times during fever but there is no history of seizure and
unconsciousness.
Contd..
• He was a diagnosed case of mild BEP.
• He mentioned, during this period he had a frequency of urine which
persist for 3 to 4 days. But he has no burning sensation or any other
urinary symptoms.
• He added that , he had constipation for 3 to 5 days .before this, his
bowel habit was normal.
• After admission in hospital ,he developed pitting bipedal edema.
• He is normotensive and diabetic for 8 years. But during fever his RBS is
15.9 mmol/l.
• On general examination, mild jaundice and clubbing present.edema
present.anemia,leukonychia,koilonychia absent.
Contd..

• On systemic examination,tenderness present on deep

palpation specially on right hypochondrium region.No
organ or mass is palpable.there is no ascites.
• There is no history of joint pain,headache or weightloss.
• other system reveales no abnormalities.
What is your provisional diagnosis ?
Provisional diagnosis :

• Enteric fever with BEP with Diabetes Mellitus.

Differential diagnosis :

• Dengue Fever
• Malaria
• Cholangitis
• Viral Hepatitis
• Biliary Ascariasis
• UTI
What maybe the investigation plan ?
1st line investigation ??
1st line investigation :
• CBC with ESR • Urine R/M/E
• CRP • Urine C/S
• Blood C/S • TSH,F-T4
• RBS • Lipid profile
• Ict test for malaria • S.electrolyte.
• Dengue antibody (IgG ,IgM)
• Usg of whole abdomen
• S.bilirubin
• Chest x ray
• SGPT
• S.creatinine
Cont..
ON ADMISSION:
• HB%= 14 g/dl
• ESR= 57mm in 1st hour
• Blood c/s = No growth found
• Dengue antibody IgM,IgG =
Negative
• Malaria AG ( ICT) = Negative
• S.creatinine : 0.62 gm/dl
• F-T4 : 2.08 ng/dl
• TSH : 0.302 uiu/ml
• S.ALT (SGPT) : 151 u/l
• Bilirubin : 5.1 mg/dl
 URINE R/M/E:
• Colour : D. yellow
• Appearance : L.hazy
• albumin : ++
• Sugar : ++
• Granular cast : ++

Urine for c/s:

Candida Albicans
colony ( profuse growth)
 Cont..
S. electrolyte:
• Na : 129 mmol/l
• K: 3.6 mmol/l
• Chloride : 95 mmol/l
• T- CO2: 21 mmol/l

• Lipid profile:
• Total cholesterol : 234
mg/dl
• HDL cholesterol : 25 mg/dl
• Triglycerides : 493mg/dl
• LDL cholesterol: 112 mg/dl
Usg of whole
abdomen:
2 nd line investigation??
2ND LINE INVESTIGATION
• GAMMA –GT
• Alkaline phosphatase
• Anti -HEV IgM
• HBS AG
• CA 19-9
• Albumin Creatinine Ratio.Urine
• Plasma ammonia
 Cont..

• GAMMA –GT: 960 u/l

• Alkaline Phosphatase : 314 u/l
• HBS AG: Negative
• ANTI-HEV IGM : Negative
• Serum CA 19-9 : 45.4 (normal
range : <= 37 u/l)
• Plasma ammonia : 73.0 umol/l
(normal value: 9-30 umol/)
• Albumin-creatinine ratio -
urine : 27mg/g ( Normal
range: <=30 )
3 rd line Investigation :
 MRCP
MRCP (magnetic
Resonance Cholangio
Pancreatogram):

• Enlarged Gallbladder
• No other significant
abnormality could be
detected.
Confirmatory diagnosis:
Enteric fever (?) with acalculous cholecystitis with
Candiduria with Dyslipidemia with Diabetes mellitus
with electrolyte imbalance with mild BEP.
Reort on 30.08.2022:
• ALT : 81 u/l
• Bilirubin : 1.6 mg/dl
• Lipase : 272 u/l
Treatment: on
admission:
• Inf NS (1l) - I/v @ 10 drops /min
• Inj . Azithromycin 500 mg
• Paracetamol
• Tramsulosin + Dutasteride
• Mirabegron
• Sitagliptin 50 mg
• Domperidone
• Tab Fexofenadine hydrochloride
• Inj Esomeprazole 20 mg
• Inj Tiemonium Methylsulphate
• Inj Insulin ( Actrapid) S/c
• Suppository Glycerol 4 stick P/R
Fresh order on 27.8.22:
Treatment on discharge:

• Inj. Insulin s/c – 10+10+ 6 (before meal)

• Paracetamol 500 mg if fever remains
• Silymarin 14o mg (1+0+1) for 7 days
• Lactulose - once daily at night if constipation occour
• Domperidone (1+1+1) for 1 month
• Ursodeoxycholic acid (1+0+1) for 7 days
• Cap Esomeprazole 40 mg (1+0+1) for 15 days
• Tab Tiemonium Methylsulphate 50 mg (1+1+1) for 7 days
• Tab Uromax –( 0+0+1) for 1 month
• Tab Cefuroxime 500 mg ( 1+0+1) for 7 days.
• Syp. Gaviflux – 8 hourly 1 month
• Tab. A to Z senior (1+0+1) for 1 month.
Outcome and follow up:
After clinical and radiological evaluation, he was
under supervision of Neurologist,gastroenterologist
and a surgeon. They made decision to give patient
medication for 15 days. And patient is improving
fever,rash, jaundice and electrolyte imbalance. He
was discharged with Advice. He was asked to follow
up after 15 days. If then disease persist a surgery
(cholecystectomy) will be require.