65 year old female came with chief complaints of fever with chills

This is 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 available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on 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 diagnosis and treatment plan.

I have prepared this blog under the guidance of Dr. Vinay (PGY3) , Dr. Venkat Sai(PGY1).

A 65 year old female presented with chief complaints of 

1)Fever with chills since 20 days 

2)B/L pedal edema 20days back. 

3)loose stools since 8 days 

4)SOB since 3 days 

5) decreased urine output since 3 days.

She was apparently alright 20 days back then she developed fever which was high grade , intermittent, associated with chills, Cough (dry) since 10days. She developed bilateral pedal edema 20days back. Then she was admitted to hospital in nalgonda and was treated for 10 days. She was diagnose to have renal abscess . Her pedal edema subsided two days back. She has been  passing black coloured stools since 3 days. She stopped eating since 10 days .

Daily routine: 

She wakes up at 5am does household work,  then drinks Java at 9am then she did farming. She used to have rice for lunch at 1pm. Then she does household work and used to have chapati for dinner. 

Past history: 

She is k/c/o HTN since 10 years. 

K/c/o DM since 10 years

N/k/c/o TB, ASTHMA, CAD, EPILEPSY. 

Personal history:

Diet- mixed 

Appetite - decreased since 20 days 

Sleep-

Bowel - black coloured stools since 3 days bladder - decreased urine output 

General examination

On examination patient is concious, coherent and cooperative. Well oriented to time , place and person. 

Vitals : 

BP -150/90 mmHg on presentation 

PR- 123bpm

RS - BAE +

CVS- S1, S2 heard

CNS - NAD. 

GRBS- 591 mg/dl

SPO2 - 88%  

Provisional diagnosis:ATYPICAL PNEUMONIA 2° ? CAP? HAP ? 

DIARRHOEA 2° ? STRONGYLOIDES/?DRUG INDUCED 

RIGHT KIDNEY ? RENAL ABSCESS 

WITH UNCONTROLLED TYPE 2 DM WITH HTN SINCE 10 YEARS 

Investigations

Chest x-ray PA view  27/09/22

USG -

Impression: hypoechoic area and noted 

 Renal abscess - Rt kidney

2D echo

ECG

 

HBA1C

HEMOGRAM 

ABG 

RBS

29/09/22

29/09/22

29/09/22

Icu bed 6

65/F

S:

Loose stools 3 episodes

O: 

Pt is concious coherent and cooperative

Temp-97.9°F

BP-120/80MMHG

PR-92BPM

CVS-S1,S2 +

RS- BAE+, CREPTS+, 

SPO2 - 94% @ROOM TEMP. 

A: ATYPICAL PNEUMONIA 2° ? CAP, ? LEGIONELLA

WITH UNCONTROLLED TYPE 2 DM WITH HTN SINCE 10 YEARS 

P:

IV FLUIDS  NS, RL- @100 ML/HR

INJ. MEROPENEM 500 MG IV/BD

TAB. AZITHROMYCIN 500MG PO/OD

INJ. ZOFER 4 MG IV/BD

INJ. HAI SC/TID (inform pg)

ORS 1 SACHET IN 1LIT. WATER. 

30/09/22

Icu bed 6

65/F

S:

Loose stools 5-6episodes

Fever spikes +

UNCONTROLLED SUGARS( RESOLVED)

O: 

Pt is concious coherent and cooperative

Temp-99.6°F

BP-100/60MMHG

PR-92BPM

CVS-S1,S2 +

RS- BAE+, CREPTS+, 

SPO2 - 93% @ROOM TEMP. 

GRBS: 104mg/dl

A: ATYPICAL PNEUMONIA 2° ? CAP, ? LEGIONELLA

WITH UNCONTROLLED TYPE 2 DM WITH HTN SINCE 10 YEARS 

P:

IV FLUIDS  NS, RL- @100 ML/HR

INJ. MEROPENEM 500 MG IV/BD

INJ. ZOFER 4 MG IV/BD

INJ. HAI SC/TID (inform pg)

TAB. LOPERAMIDE 4MG/PO/BD

ORS 1 SACHET IN 1LIT. WATER.

1/10/22

AMC bed 6

65/F

S:

Loose stools 5-6episodes( resolved )

Fever spikes -

UNCONTROLLED SUGARS( RESOLVED)

Nausea present

O: 

Pt is concious coherent and cooperative

Temp-98.6°F

BP-100/60MMHG

PR-99BPM

RR-28CPM

CVS-S1,S2 +

RS- BAE+, CREPTS+, 

SPO2 - 98% @ROOM TEMP. 

GRBS: 208mg/dl

A: ATYPICAL PNEUMONIA 2° ? CAP

 TYPE 2 DM SINCE 10 YEARS ,HTN SINCE 10 YEARS 

P:

IV FLUIDS NS, RL- @100 ML/HR

INJ. ZOFER 4 MG IV/TID

INJ.PAN 40MG IV/OD

INJ. HAI SC/TID acc. To GRBS

INJ. LINEZOLID 600MG PO/BD

TAB. AZITHROMYCIN 500MG PO/OD

BP/PR/RR/TEMP / CHARTING

GRBS CHARTING 2nd HRLY

2/10/22

AMC bed 6

65/F

S:

Loose stools subsided 

No Fever spikes 

No hypoglycemic episodes 

Nausea present

O: 

Pt is concious coherent and cooperative

Temp-98.6°F

BP-110/70MMHG

PR-86BPM

RR-25CPM

CVS-S1,S2 +

RS- BAE+, CREPTS+, 

SPO2 - 98% @ROOM TEMP. 

GRBS: 124mg/dl

A: ATYPICAL PNEUMONIA 2° ? CAP ? HAP

RIGHT KIDNEY ? RENAL ABSCESS. 

DIARRHEA 2° TO STRONGYLOIDES/ DRUG INDUCED 

 TYPE 2 DM SINCE 10 YEARS ,HTN SINCE 10 YEARS 

P:

PLENTY OF ORAL FLUID 2-3L /DAY

IV FLUIDS NS, RL- @100 ML/HR

INJ. ZOFER 4 MG IV/TID

INJ.PAN 40MG IV/OD

INJ. DOMPERIDONE 10 MG/IV/TID

INJ. HAI SC/TID acc. To GRBS

TAB. LINEZOLID 600MG PO/BD

BP/PR/RR/TEMP / CHARTING

GRBS CHARTING 6TH HRLY

BBF-BL-BD-2am

MONITOR VITALS AND INFORM SOS 

Discussion 

What is the cause of decrease in the hemoglobin? 

21 year old male with altered sensorium

Pt came to casualty in state of altered sensorium with slurring of speech since yesterday

Pt does hotel management and stays alone.

 He was apparently asymptomatic 5 days back. He had fever 5 days back which was high grade, continuous, associated with chills and rigors. No history of cold and cough . He went to local hospital got treated but the fever did not subside.

Later after a day he consumed beer, had biryani.

He had 1 episode of vomiting and loose stools since 3 days. (2 days back), while he was in room suddenly he had involuntary movements of all 4 limbs associated with frothing, uprolling of eyes, post ictal confusion, he bit his lower lip  no tongue bite . He had 1 episode of vomiting at the time of involuntary movement, and loose stools. 

Loose stools, foul smelling. 

Since yesterday afternoon, pt was in altered sensorium , with slurred speech, and deviation of mouth.

He presented to hospital on 19/09/22 and was treated he was sedated at 1am  was sent home at 4:30am . He woke up at 2pm . He had altered sensorium and involuntary movements. 

No c/o weakness of upper limb and lower limb.

No h/o cough, cold, palpitations, syncopal attacks, chest pain

PAST HISTORY 

N/k/c/o - DM, HTN, EPILEPSY,TB , ASTHMA 

FAMILY HISTORY

No significant history 

PERSONAL HISTORY

appetite- normal 

Diet- mixed

Bowel and bladder - normal 

Sleep- regular

Habits - alcohol consumption occasionally,

Smoking 

General examination:

On examination: 

Pt is in altered sensorium

No pallor, Icterus, clubbing, cyanosis lymphadenopathy, edema

VITALS

BP 110/60mmHg

PR 110bpm

Temp. 100°F

CVS S1, S2 +

RS - BAE +, NVBS

CNS EXAMINATION:

NERVOUS SYSTEM EXAMINATION 

a. Conscious

 b. Not Oriented to time, place and person

 c. Speech and language –no aphasia, dysarthria, dysphonia 

d. Memory – immediate-retention and recall, recent and remote - not intact 

MOTOR examination 

Meningeal signs

Kernigs sign +

Brudzinski sign -

Power:

                       Rt.                   Lt

UL                 +4/5.              -4/5

LL.                +4/5.              -4/5

Tone 

UL.                N                        N

LL.                 N.                       N

Hand grip:  100%.                100%

Provisional Diagnosis: MODS (Meningoencephalitis, Hepatitis & Glomerulonephritis) due to ? Systemic Vasculitis associated with ? Rickettsial Spotted Fever ? Viral Hemorrhagic Fever ? HUS/TTP

Investigations

21/09/22

PT 16SEC

INR 1-11 SEC

 Hemogram

Urinary electrolytes

CUE

Urine protein /creatinine ratio

23/09/22 

Treatment 

21/09/22

1)IVF NS , RL @100ML/hr

2)INJ. ZOFER 4MG IV/SOS

3)INJ. THIAMINE 200MG IN 100ML NS/IV/TID

4)STRICT I/O CHARTING

5)BP/PR/RR/SPO2 2nd Hrly.

22/9/22

O/E 

Patient was agitated, talking to self, irritable

BP- 120/90 mmHg

PR - 96bpm

CVS- S1 S2 + 

RS- BAE+ , NO ADDED SOUNDS

P/A- SOFT

A: ALTERED SENSORIUM UNDER EVALUATION 2° TO ? DENGUE ENCEPHALITIS WITH PRE RENAL AKI WITH VIRAL HEPATITIS. 

P 

IVF NS, DNS @70ml/hr

INJ. ZOFER 4mg/IV/SOS

INJ. THIAMINE 2OO mg in 100 ml NS IV/TID

STRICT I/I CHARTING

SYP. DUPHALAC 15ML PO/TID

TAB DOXY 100 mg/ RT/BD

24/09/22

S: agitated, non co-operative 

O: 

Pt concious

Temp : 98.7

BP: 140/90mmHg

PR - 72bpm

CVS S1 S2 + 

RS - BAE+

P/A- soft, tender

GCS- E4V5M6

A: altered sensorium under evaluation 2° dengue encephalitis with pre-renal AKI (resolved)

with viral hepatitis with alcohol withdrawal syndrome with MODS

P:

1) IVF NS,DNS @75 ml/hr

2) INJ.DOXY 100mg/IV/BD

3) INJ. DEXA 8mg/IV /TID 

4) INJ. THIAMINE 200mg in 100ml NS/IV/BD

5) SYP. DUPHALAC 30ml PO/TID

6) STRICT I/O CHARTING

7) BP/PR/SPO2 MONITORING 2ND HRLY. 

25/09/22

ICU bed 4

21year old male 

S: sensorium improved 

Fever spikes+

O: 

Pt concious

Temp : 100.7

BP: 140/90mmHg

PR - 70bpm

CVS S1 S2 + 

RS - BAE+

P/A- soft, tender

GCS- E4V5M6

A: altered sensorium under evaluation 2° ? TTP 

? Viral encephalitis with renal AKI (glomerulonephritis)

with viral hepatitis  with MODS.

P:

1) IVF NS,DNS @75 ml/hr

2) INJ.DOXY 100mg/IV/BD

3) INJ. DEXA 8mg/IV /TID 

4) INJ. THIAMINE 200mg in 100ml NS/IV/BD

5) SYP. DUPHALAC 30ml PO/TID

6) STRICT I/O CHARTING

7) BP/PR/SPO2 MONITORING 2ND HRLY. 

26/9/22

S:Sensorium improved

   No fever spikes

O: Pt is conscious,coherent 

Cooperative 

BP-110/90

Pr-76

Temp-98.1f

CVS-S1S2+

P/A -soft,NT

Spo2-95%

A:ALTERED SENSORIUM UNDER EVALUATION secondary to  ?TTP  with pre-renal AKI(resolved) 

with viral hepatitis with alcohol withdrawal syndrome with MODS

P:Plan for treatment 

1.Plenty of oral fluids

2.INJ DOXY 100mg/IV/BD

3.INJ DEXA 8mg/IV/BD

4.INJ THIAMINE 200mg in 100mlNs/IV/OD

5.SYP DUPHALAC 30ml PO/TID

6.Strict I/O charting

80 year old male pt presented in unresponsive state

This is 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 available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on 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 diagnosis and treatment plan.

I have prepared this blog under the guidance of Dr. Vinay (PGY3) , Dr. Venkat Sai(PGY1).

80 year old male 

Chief complaints: 

Presented to casualty in unresponsive state since 2hrs on 14/09/22

He was apparently asymptomatic one day back then he presented to the casualty in an unresponsive state since 4am associated with profuse sweating.

His day starts at 5am , he Wakes up and sits for a while then he walks his around with goat that he has been rearing. He does his breakfast at 8am, lunch at 3pm sleeps for a while and then rears the goat for a while then , dinner at 7pm . He Sleeps at around 8-9 pm . He wakes in the middle of the night sometimes if he were hungry and eats rice with milk and goes back to sleep. 

On the night of incident he had his dinner at 7pm and went to bed around 9. He woke up at 12 and had rice with milk at 12am and went back to sleep. Later at 5 am he woke up hungry and had rice with milk . In a few minutes he fell on to the bed and was asking for help . He was taken to govt. hospital nearby where he was given treated and then referred to our hospital where he presented in an unresponsive state. 

Past history : 

H/o fever 1 year back which lasted for 1 week it was associated with chills and rigors, cough . He also complained of breathlessness. - he went to local hospital and was given medication for 1 month. The fever subsided and he was doing fine

No similar complaints in the past . Non alcoholic, non smoker. No h/o drug usage

No c/o SOB , Orthopnea, PND No chest pain / palpitations/syncopal attacks. 

H/o fever 20 days back 

N/k/c/o HTN /DM/CAV / TB/ EPILEPSY

Personal history: 

Diet : mixed 

Appetite: normal

Sleep : regular

Bowel and bladder: regular

Addictions: he used to consume alcohol  occasionally 90ml whisky during festivals. Stopped consuming alcohol since 2 years 

No h/o smoking

On general examination

 Patient was concious, unresponsive

No pallor, Icterus, clubbing, cyanosis, edema , lymphadenopathy

Vitals : 

Temp. 98.3°F 

BP - 160/90mmHg

PR- 86bpm

CVS- S1 S2 + , loud s2

RS- BAE +

P/A- soft. NT

GRBS -64mg/dl 

Provisional diagnosis:  recurrent Hypoglycemia resolved ,

Type II respiratory failure. 2° to ? CAP with old ? PTB . 

Investigations : 

14/09/22

                               Hemogram 

ABG at 9:48am

 ABG at 4:40pm

RFT 

Chest x-ray 

USG

15/09/22

Hemogram 

                                

ESR - 20 mm/ 1st hr.

Serum creatinine - 0.8 mg/dl

Serum electrolytes - 

Na- 136mEq/L

K- 3.3 mEq/L

Cl - 0.86 mmol/L

                 ABG 

CUE

15-09-22

Treatment 

1) INJ. 25 % DEXTROSE @ 50 ml/ hr (target range

: 120-180mg/dl)

2) NEBULIZATION T DUOLIN 6th hrly, BUDECORT 8th hrly

3) BP, PR, RR, CHARTING 4th hrly. 

4) INJ. LASIX 20 mg stat. 

16-09-22

Abg1

Abg2

Abg3

S: pt. Is sedated and paralysed 

O :

Pt is , on mechanical ventilator

Temp- 98.0 °F

PR:88bpm

BP:100/60

CVS: S1 S2 +, LOUD S2

RS: BAE+

SpO2 100% , 

TFiO2 - 40

RR- 25

PEEP- 8

I:E- 1:3

Peak - 20

TV -300ml

GRBS- 187 mg/dl ,

P/A: soft , non tender 

A: recurrent hypoglycemia 2° ? Insulin auto immune syndrome, ? Sepsis ? PTB

Type 2 respiratory failure 2° to CAP 

P:

1)INJ. 25% DEXTROSE @15ml/hr to maintain RBS 120-180mg/dl

2) IVF- NS 30 ml/hr

3) INJ. LASIX 20mgIV/BD 

4) RT FEEDS @75ml/2nd hrly

5) INJ. MIDAZOLAM 10ml +40ml NS @ 5ml/hr 

6) INJ ATRACURIUM 5ml+ 45ml NS @ 5ml/hr

7) BP/PR/RR/SPO2/GRBS CHARTING

8) AIR BED. 

17/09/22

Hemogram

ABG

18/09/22

Hemogram

RFT

19/09/22

Hemogram

RFT

S:SOB improved 

O :

Pt is concious , coherent and cooperative 

Temp- 99.8°F

PR:91bpm

BP:100/60mmHg

CVS: S1 S2 +

RS: BAE+, NVBS

CNS: NAD

SpO2: 98%

GRBS- 112 mg/dl ,

P/A: soft , non tender 

A: recurrent hypoglycemia 2°  ? Insulin auto immune syndrome, ? Sepsis ? 

Type 2 respiratory failure 2° to ? active PTB ?CAP 

P:

1) IVF- NS @ 30 ml/hr

2) INJ. LASIX 20mgIV/BD 

3) TAB.ISONIAZID 75mg

     TAB.RIFAMPICIN 150mg

     TAB. PYRAZINAMIDE 400mg

     TAB. ETHAMBUTOL 275mg

     (3 TAB PO/OD)

4)BP/PR/RR/SPO2/GRBS CHARTING

5) AIR BED. 

22/09/22

S:SOB improved 

O :

Pt is concious , coherent and cooperative 

Temp- 98.0°F

PR:80bpm

BP:110/80mmHg

CVS: S1 S2 +

RS: BAE+

CNS: NAD

SpO2: 92% with 2L of O2 and over night CPAP

GRBS- 80 mg/dl ,

P/A: soft , non tender 

A: 

Type 2 respiratory failure 2° to ? active PTB ?CAP 

Recurrent hypoglycemia resolved, secondary to ? IAS , PTB 

P:

1) IVF- NS @ 30 ml/hr

2) TAB.ISONIAZID 75mg

     TAB.RIFAMPICIN 150mg

     TAB. PYRAZINAMIDE 400mg

     TAB. ETHAMBUTOL 275mg

     (3 TAB PO/OD)

3)ABG 6TH HRLY

4)BP/PR/RR/SPO2/GRBS CHARTING

5) AIR BED. 

24/09/22

S:SOB improved 

O :

Pt is concious , coherent and cooperative 

Temp- 98.7°F

PR:104bpm

BP:110/70mmHg

CVS: S1 S2 +

RS: BAE+, B/L basal crepts

CNS: NAD

SpO2: 88% 

GRBS- 80 mg/dl ,

P/A: soft , non tender 

A: 

Type 2 respiratory failure 2° to ? PTB 

Recurrent hypoglycemia resolved, secondary to ?sepsis

P:

1) IVF- NS @ 50 ml/hr

2) O2 INHALATION TO MAINTAIN SPO2 >/= 92%

3) TAB.ISONIAZID 75mg

     TAB.RIFAMPICIN 150mg

     TAB. PYRAZINAMIDE 400mg

     TAB. ETHAMBUTOL 275mg

     (3 TAB PO/OD)

3) INTERMITTENT BIPAP 

4) ABG 6TH HRLY

5)BP/PR/RR/SPO2/GRBS CHARTING

6) INFORM SOS

25-09-22

ICU bed 6,

80year old male. 

S:SOB improved 

O :

Pt is concious , coherent and cooperative 

Temp- 97.6°F

PR:74bpm

BP:120/80mmHg

CVS: S1 S2 +

RS: BAE+, B/L basal crepts

CNS: NAD

SpO2: 88% 

GRBS- 61mg/dl ,

P/A: soft , non tender 

A: 

Type 2 respiratory failure 2° to ? PTB (clinico radiographic)

Recurrent hypoglycemia (resolved), secondary to ?sepsis

P:

1) IVF- NS @ 50 ml/hr

2) O2 INHALATION TO MAINTAIN SPO2 >/= 92%

3) TAB.ISONIAZID 75mg

     TAB.RIFAMPICIN 150mg

     TAB. PYRAZINAMIDE 400mg

     TAB. ETHAMBUTOL 275mg

     (3 TAB PO/OD)

3) TAB.MET-XL 25mg PO/OD

4) INTERMITTENT BIPAP 

5) ABG 6TH HRLY

6)BP/PR/RR/SPO2/GRBS CHARTING

7) INFORM SOS

26/9/22

S: Pedal edema

    Thrombophelbitis

   SOB improved 

O: Pt is conscious,coherent 

Cooperative 

BP-100/60

Pr-74bpm

Temp-Afebrile

RR- 16cpm

CVS-S1S2+

P/A -soft,NT

A: 

Type 2 respiratory failure secondary to? PTB(clinicoradiological)

Recurrent hypoglycemia (resolved) 

secondary to ? Sepsis

P:plan for treatment 

1.Tab lasix 40mg/PO/OD

2.Oral fluids@ 1-1.5l

3.O2 inhalation to maintain Spo2- >92%

4.INTERMITTENT BIPAP

5.TAB MET-XL 25mg/PO/OD

6.TAB RIFAMPICIN 150mg

  TAB ISONIAZID 75mg

   TAB PYRAZINAMIDE 40mg

   TAB ETHAMBUTHOL 275mg

    (3TAB PO/OD)