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?