66yr old male with fever 3 days and DM 2 20 years

 June 07, 2023

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


Case report

 

A 66 year old daily labourer by occupation presented with chief complaints of high grade fever since 3 days and generalized weakness since 1 day.


Patient was apparently asymptomatic 3 days back when he went to some function and then the next day he developed high grade fever insidious in onset that is associated with chills and rigors, intermittent type relived with medication without any diurnal variation.

Then the patient went to a local doctor where he was prescribed with some medication and his fever got relieved on taking medication.

Then he developed generalized weakness which is insidious in onset due to which he was unable to perform routine activity and was brought to our hospital.

H/O giddiness present since yesterday, H/O fall present (two times), H/O Loss of conciousness for 5 min

No H/O SOB, chest pain, palpitations

No H/O cough, cold, vomiting.


Daily routine

Patient wakes up at 6 am then gets freshened up, takes tea at 7 am eats breakfast at 8 am and then goes to work as a daily labourer and then comes back home at 1 pm takes lunch then sleeps for 2 hours then takes tea at 6 pm and eats dinner at 8 30 pm and goes to sleep by 9 30 pm.


Past history

K/c/o DM 2 since 20 years and is on regular medication since then.

When patient went to a local doctor his blood pressure was high and was told to take antihypertensive medication since 2 days.

Not a k/c/o asthma, epilepsy, CAD, CVA, thyroid disorders.

Patient is a known case of FILARIASIS of left lower limb and scrotum.






Personal history

He takes mixed diet with normal appetite and has regular bowel and bladder movements.

He takes alcohol daily since 1 year.


Family history

No significant family history


General examination

Pallor is present.

No features indicating the presence of icterus, cyanosis, clubbing, edema lymphadenopathy.









SYSTEMIC EXAMINATION


ABDOMINAL EXAMINATION

INSPECTION

No distention,No scars

Umbilicus - Inverted

Equal symmetrical movements in all the quadrants with respiration.

No visible pulsation,peristalsis, dilated veins and localized swellings.

PALPATION

No local rise of temperature, Abdomen is soft with no tenderness.

No spleenomegaly, hepatomegaly.

PERCUSSION

Liver span is 12cm, No hepatomegaly

Fluid thrill and shifting dullness absent.

No puddle sign.

AUSCULTATION

Bowel sounds present.

CVS- S1 and S2 heart sounds heard. 

RS- Bilateral air entry is present, normal vesicular breath sounds heard.

CNS EXAMINATION

Right Handed person, uneducated 

HIGHER MENTAL FUNCTIONS:

Conscious, oriented to time place and person.

speech : muffled, unclear

Behavior : normal 

Memory : Intact.

Intelligence : Normal

No hallucinations or delusions.

CRANIAL NERVE EXAMINATION:

Intact

MOTOR EXAMINATION:        

               Right Left

BULK UL Normal Normal

            LL Normal Normal

TONE UL Normal Normal

             LL Normal Normal

POWER UL 5/5 5/5 LL 5/5 hypotonic?

REFLEXES

                           Right Left

BICEPS ++.   ++

TRICEPS +++ ++

SUPINATOR +  +

KNEE +++                       ++

ANKLE -    -    

PLANTAR flexor flexor

SENSORY EXAMINATION: intact


PROVISIONAL DIAGNOSIS

VIRAL PYREXIA 

DM 2 SINCE 20 YRS


INVESTIGATIONS


ECG


Chest xray



SEROLOGY

HBsAG- Positive

HIV, HCV- Negative

USG Abdomen


Grade 1 RPD changes in Left kidney

Left simple renal cortical cyst


CBP 6/6/23


Lft

6/6/23


Cue



FBS- 70mg/dl

PLBS-167mg/dl

Blood urea-37mg/dl

Serum creatinine- 1.8mg/dl

Serum electrolytes-6/6/23



MRI brain 


Treatment

Inj.Monocef 1gm IV/BD

Tab.Dolo 650mg PO/TID

Inj.Neomol 1gm IV/SOS if temp more than 101 F

Soap notes  

8/6/2023

AMC BED 5 - 66M

S:  

Fever spikes present 

O:

Patient is drowsy

BP: 130/80 mmHg

PR: 94 bpm

RR: 24 cpm.                             

Spo2: 98%                         

CVS: S1 s2 heard , no murmurs RS: B/L air entry present No added sounds 

CNS: No FND

A: 

Viral pyrexia ?Typhoid fever 

K/c/o DM 2 since 20 years

P: 

1)Inj.Monocef 1gm/IV/Bd (D2)

2)IV fluids NS@100ml/hr

3)Inj.Neomol 1gm/IV/SOS

4)Inj.HAI according to GRBS >200mg/dl

5)Tab.Dolo 650mg/PO/TID


Soap notes 

9/6/23 

AMC bed 5

S: 

Fever spikes present 

O: 

Pt is conscious, coherent and cooperative 

BP - 130/80 mmHg

PR- 80 bpm 

RR - 18 cpm 

Temp - 100 F

GRBS - 167 mg/dl 

SpO2 - 99% @RA

CVS - S1 S2 heard , no murmurs 

RS - BAE+ no added sounds 

P/A - soft and non tender 

CNS - no FND

A: 

PYREXIA ? TYPHOID FEVER K/C/O DM II SINCE 20 YEARS WITH HBsAg + 

P:

INJ. MONOCEF 1 G IV/BD

IV FLUIDS NS @ 100 ml/hr 

INJ NEOMOL 1 G IV/SOS

TAB DOLO 650 MG PO/TID

INJ HAI ACCORDING TO GRBS


Soap notes 

10/6/23 

AMC bed 5


S: 

Fever spikes present yesterday

Did not pass stools since 2 days 

O: 

Pt is drowsy

BP - 140/60 mmHg

PR- 97 bpm 

RR - 16 cpm 

Temp - 100 F

GRBS - 235/dl 

SpO2 - 98% @RA

CVS - S1 S2 heard , no murmurs 

RS - BAE+ no added sounds 

P/A - soft and non tender 

CNS - no FND

A: 

PYREXIA SECONDARY TO ? TYPHOID FEVER 

                                             ? MENINGITIS 

K/C/O DM II SINCE 20 YEARS WITH HBsAg +

P:

(D5) INJ. MONOCEF 1 G IV/BD

(D4) INJ DOXYCYCLINE 200 MG IV/BD

IV FLUIDS NS @ 100 ml/hr 

INJ NEOMOL 1 G IV/SOS

TAB DOLO 650 MG PO/TID

INJ HAI ACCORDING TO GRBS

Soap notes
11/6/23 
AMC bed 5
S:
Pt subjectively feeling better . 
Dysphagia has reduced 
Did not pass stools since 3 days 
O:
Pt is drowsy
BP - 150/90 mmHg
PR- 80 bpm 
RR - 20 cpm 
Temp - 100 F
GRBS - 174/dl 
SpO2 - 98% @RA
CVS - S1 S2 heard , no murmurs 
RS - BAE+ no added sounds 
P/A - soft and non tender 
CNS - 
Tone 
 Rt UL Normal 
Lt UL normal
Rt LL Normal
Lt LL hypotonic ? 
Power 
 Rt UL : 5/5
Lt UL : 5/5 
Rt LL : 5/5
Lt LL : - 
Reflexes        Rt Lt 
B ++ ++
T +++ ++
S + + 
K +++ ++
A - -
P Flexion flexion

A: 

PYREXIA SECONDARY TO ? TYPHOID FEVER 
                                             ? MENINGITIS 

K/C/O DM II SINCE 20 YEARS WITH HBsAg +

ACUTE INFARCT IN RIGHT FRONTAL LOBE ( PARASAGGITAL CORTEX ) ( ACA TERRITORY)

P:

(D6) INJ. MONOCEF 1 G IV/BD
(D5) INJ DOXYCYCLINE 200 MG IV/BD
IV FLUIDS NS @ 100 ml/hr 
INJ NEOMOL 1 G IV/SOS
TAB DOLO 650 MG PO/TID
TAB. AFORVOSTATIN + CLOPIDOGERL + ASPIRIN 20MG PO/HS /9PM
TAB. TENOGOVIR 300MG PO/OD ( ALTERNATE DAY --- NEXT DOSE (12/6/23)) 
INJ HAI ACCORDING TO GRB
Soap notes 
12/6/23 
AMC bed 5
S: 
Pt subjectively feeling better . 
Generalized weakness resolving, no fever spikes 
O: 
Pt is c/c/c
BP - 150/90 mmHg
PR- 80 bpm 
RR - 20 cpm 
Temp - 100 F
GRBS - 256/dl 
SpO2 - 98% @RA
CVS - S1 S2 heard , no murmurs 
RS - BAE+ no added sounds 
P/A - soft and non tender 
CNS - HMF intact
Tone 
 Rt UL Normal 
 Lt UL normal
Rt LL Normal
Lt LL hypotonic ? 
Power 
 Rt UL : 5/5
Lt UL : 5/5 
Rt LL : 5/5
Lt LL : - 
Reflexes   
         Rt Lt
B ++ ++
T +++ ++
S + + 
K +++ ++
A - -
P Flexion flexion
A: 
PYREXIA SECONDARY TO ? TYPHOID FEVER 
                                             ? MENINGITIS 
K/C/O DM II SINCE 20 YEARS WITH HBsAg +
ACUTE INFARCT IN RIGHT FRONTAL LOBE ( PARASAGGITAL CORTEX ) ( ACA TERRITORY)
P:
(D6) INJ. MONOCEF 1 G IV/BD
(D5) INJ DOXYCYCLINE 200 MG IV/BD
IV FLUIDS NS @ 100 ml/hr 
INJ NEOMOL 1 G IV/SOS
TAB DOLO 650 MG PO/TID
TAB. ATORVOSTATIN + CLOPIDOGERL + ASPIRIN 20MG PO/HS /9PM
TAB. TENOFOVIR 300MG PO/OD ( ALTERNATE DAY --- NEXT DOSE (13/6/23)) 
INJ HAI ACCORDING TO GRBS

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