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
USG -
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?