Tuesday, September 27, 2022

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? 

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