55 yr old with fever and SOB

 This is an 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 global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the 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 a diagnosis and treatment plan

55 year old female came with chief complaints of 

• Fever since 4 days

• SOB since 4 days

HOPI:  The patient was apparently asymptomatic 4 days back , then developed  she had a H/o RTA ( Fracture of left lowerlimb) S/p wound debridement with external fixator under spinal anaesthesia)

H/o pus discharge from external fixator site.

Grade 4 SOB progressive in nature ( At rest) a/w lower back ache and generalised body pains.

 , progressive in nature

, high grade , relieved on medication.

PAST HISTORY:  k/c/o Diabetes mellitus 2

Not a K/c/o HTN, TB,CVA ,CAD ,Epilepsy ,Asthma

PERSONAL HISTORY:

Diet: Mixed

Appetite: Normal

B&B: Regular 

Addictions: No addictions.

O/E

General examination 

Temp: 98.9 F

PR: 100 bpm

BP: 130/90 mm hg

RR:  22 cpm

SpO2: 98% @ RA

GRBS: 387 mg / dl

Systemic examination 

CVS: S1S2 + , No murmurs

RS: BAE + , NVBS

P/A: Soft , NT

CNS:  No FND

INVESTIGATIONS

TREATMENT:

IVF NS & RL continuous infusion @ 180 ml/hr

Inj. HAI 8 units/IV/STAT

Inj. HAI 10 ml in 39 ml NS IV @ 6ml/hr

Inj. MEROPENEM 1gm IV/BD

Inj. VANCOMYCIN 1 gm in 100 ml NS IV/BD

Inj. PAN 40mg IV/OD

GRBS Monitoring hourly 

IVF 25% Dextrose if GRBS is more than 150 mg/dl.

47 year old male with fever ,headache and altered sensorium

 Jan 18, 2022

 

CHIEF COMPLAINTS:

Patient came to the hospital with the chief complaints of - fever , headache , altered talking ,walking n confusion.

HOPI:

Patient was apparently asymptomatic 5days back .Then developed-

 High grade fever with chills, intermittent in nature, relieved on medication and was associated with  headache.

Altered sensorium since 2 to 3 hours (not talking and not working properly).

No urine output since morning on 24-3-22

No history of  burning micturition,  vomiting, loose stools,  SOB,  cough ,chest pain, bleeding manifestations.

pERSONAL HISTORY:

Diet- mixed

Appetite- decreased since 3 days

Sleep - indequate

Bowel - regular

Bladder - decreased urine output on 24-3-22

PAST HISTORY:

N/K/C/O DM ,HTN,BA,TB, CVA,CAD, epilepsy

ADDICTIONS:

Smokes ,montly once and was a occasional drinker but stopped 1 month back.

No significant drug history

FAMILY HISTORY : not significant

GENERAL EXAMINATION: 

Patient is oriented to time ,place and person

Poorly built and poorly nourished.

Examined under a well lit room.

No Pallor /Icterus /Cyanosis/clubbing/Edema of feet  /Lymphadenopathy.

VITALS :  

Temp :  101  F 

PR : 90 bpm

BP : 140/80 mmhg 

RR : 18 

SPO2 : 98 % at RA 

GRBS-122 mg/dl

SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM :  S1 and S2 heard, no murmurs heard .

RESPIRATORY SYSTEM : Bilateral air entry present ,  clear .

PA : soft and non tender

CNS:

GCS-

E4V3M6, 

pupils- B/L NSRL

HIGHER MENTAL FUNCTIONS:

• Oriented to time,place,person
• Memory : immediate,recent, remote intact
• Speech: normal
• No delusions or hallucinations

CRANIAL NERVES: 

1- normal

2- not tested

3,4,6- No restriction of movement of eye

5-normal( muscles of mastication+sensations of face)

 

7- normal

8- Normal hearing

9,10- No difficulty in swallowing and speech, gag reflex not tested

11,12- normal.

  MOTOR SYSTEM EXAMINATION :

TONE:  normal

POWER :                    Right       Left

     

    Upper limb          5/5             5/5

    Lower limb          5/5             5/5

Reflexes :                 Right                Left

1. Biceps:             2+                      2+
2. Triceps:             2+                 2+
3. Supinator:              2+        2+
4. Knee:               2+                       2+
5. Ankle:               2+                        2+

Plantars:            extensor          Flexor

Babinski - negative

Meningeal signs-

Neck stiffness -present 

Kernigs sign - positive.

SENSORY EXAMINATION:

Normal

CEREBELLUM EXAMINATION:

• Able to do finger nose test.
•  Dysdiadokinesia present
• No rebound tenderness 
• Gait: could not be elicited

AUTONOMIC NERVOUS SYSTEM:

• No abnormal sweating
• No resting tachycardia

MRI Impression (24-3-22)

- Few lacunar infarcts in medulla on left side.No f/o raised ICT on MRI 

Chest x-ray (24-3-22)

Ultrasound report (24-3-22)

ECG

Opthal- fundoscopy i/v/o any raised ICT for  LP

Blood culture report (26-3-22)

Urine culture report(26-3-22)

Fever charting

TREATMENT: 

On 24-3-22

IVF NS ,RL ,DNS@100 ml/hr

INJ PANTOP 40 MG IV/OD

INJ.NEOMOL 1 GM IV SOS

INJ. MONOCEF 2 GM IV BD

INJ. DEXA 8 MG IV STAT

TAB DOLO 650 MG RT/SOS

BP,PR monitoring 4 th hourly

On 25-3-22

IVF NS ,RL ,DNS@100 ml/hr

INJ PANTOP 40 MG IV/OD

INJ.NEOMOL 1 GM IV SOS if temp >101°F

INJ.Thiamine 1 amp in 100ml NV/IV/OD

INJ. MONOCEF 2 GM IV BD

INJ. DEXA 4 MG IV STAT

INJ DOXY 100 mg IV BD

Strict  I/O charting

W/f seizure activity

INJ. Vancomycin 2mg IV stat

INJ.Optineuron 1amp + 500ml NS over 1hr

BP,PR monitoring 4 th hourly

On 26-3-22

IVF NS ,RL ,DNS@100 ml/hr

INJ PANTOP 40 MG IV/OD

INJ.NEOMOL 1 GM IV SOS

INJ.Thiamine 1 amp in 100ml NV/IV/OD

INJ. MONOCEF 2 GM IV BD

INJ. DEXA 4 MG IV STAT

INJ DOXY 100 mg IV BD

TAB DOLO 650 pO TID

Strict  I/O charting

W/f seizure activity

INJ. Vancomycin 1mg IV BD

INJ.Optineuron 1amp + 500ml NS over 1hr

BP,PR monitoring 4 th hourly

On 27-3-22

IVF NS ,RL ,DNS@100 ml/hr

INJ PANTOP 40 MG IV/OD

INJ.NEOMOL 1 GM IV SOS

INJ.Thiamine 200mg IV BD

INJ. MONOCEF 1 GM IV BD

INJ. DEXA 4 MG IV BD

INJ DOXY 100 mg PO BD

TAB DOLO 650 pO TID

Strict  I/O charting

W/f seizure activity

INJ. Vancomycin 1mg IV BD

INJ.Optineuron 1amp + 100ml NS over 1hr

BP,PR monitoring 4 th hourly.

LP done on 24-3-22 at 2 am - showing around 450 cells? Lymphocyte predominant,

Glucose - 32

Protein - 195

Chloride - 120

 GRBS at time of LP - 112mg/dl

Provisional diagnosis- meningitis?

40yr old male with fever and headache

 This is an 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 patient's 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 the comment box. 

Chief complaints

>fever since 3 days

>headache since 2 days

History of presenting Illness

Patient was apparently asymptomatic 3 days ago then developed fever, high grade a/w chills, not associated with diurnal variation, relieving on medication

H/O headache present since 2 days in frontal region, continuous, 

No H/O vomiting, loose stools

No H/O nausea, abdominal distension

No H/O rash, chough, cold

No H/O burning mituration, dysurea

Past H/O

Not a K/C/O DM, HTN, thyroid disease, BA

PERSONAL HISTORY :

DIET - MIXED

APPETITE -NORMAL ,

BOWEL MOVEMENT - REGULAR , 

BLADDER MOVEMENTS - REGULAR, 

ALCOHOL ADDICTION, LAST BINGE 3 DAYS BACK 60 ML WHISKY

FAMILY HISTORY - 

NAD

ON EXAMINATION -

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 

TEMPERATURE - 99.1

PULSE RATE - 84 BPM

BLOOD PRESSURE - 110/70 MM OF HG 

RESPIRATORY RATE - 16

SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

Investigations

ECG

                                      Normal sinus rhythm

Chest X-ray

CUE (2/3/22)

Albumin: +

Sugar: ++++

Pus cells: 4-5

Epithelial cells: 3-4 

HEMOGRAM

HB 14.3

TC 2800

PLT 92000

MCV 80.2

PCV 41.2

MCH 27.5

MCH 34.3

SMEAR - NORMOCYTIC NORMOCHROMIC, WITH BICYTOPENIA

SMEAR FOR MALARIAL PARASITE - Negative

BGT - O +ve

CUE

ALB - trace

Sugar - nil

Puscells - 2-4

Epithelial cells - 2-4

HbSAg - negative

HCV - negative

HIV - negative

Dengue serology

NS1 - +ve

IgG - negative

IgM - negative

RFT

Urea- 22

Creatinine-0.9

UA-4.1

Calcium-9.2

Phosphorus-2.5

Sodium-136

Potassium-3.8

Chloride-102

LFT

TB-1.37

DB-0.47

AST-84

ALT-49

ALP-168

TP-56

ALB-3.31

Diagnosis

Viral pyrexia

Treatment

Inj. Paracetamol 1g IV Stat

IVF  NS/RL at 75ml/hr

T. Paracetamol 650mg PO TID

Day 1

Day 2 SOAP NOTES

S-C/o headache, neck pain subsided, one fever spikes today

O-

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 

TEMPERATURE - 98.1

PULSE RATE - 75 BPM

BLOOD PRESSURE - 120/80 MM OF HG 

RESPIRATORY RATE - 17

SPO2 - 100 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

HEMOGRAM

HB 16

TLC 3000

PCV 46.6

MCV 82.9

MCH 28.9

MCHC 34.2

Plt 90,000

P. S normocytic, normochromic with bicytopenia

A-

viral pyrexia with thrombocytopenia with NS1POSITIVE

P-

Inj. Optineuron in 100ml NS over 30 mins

IVF NS/RL at 150ml/hr

T. Paracetamol 650mg PO TID

SOAP NOTES DAY 3

S-C/o headache,neck pain subsided, no fever spikes today

O-

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA, no petichiae

VITALS - 

TEMPERATURE - 98.3

PULSE RATE - 82 BPM

BLOOD PRESSURE - 

110/70 MM OF HG supine

110/70 mmHg standing

RESPIRATORY RATE - 19

SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

HEMOGRAM

HB 15.9

TLC 2300

PCV 46.3

MCV 82.9 

Plt 50,000

P. S NORMOCYTIC NORMOCHROMIC WITH neutropenia and thrombocytopenia

A-

viral pyrexia with thrombocytopenia with NS1POSITIVE

P-

Inj. Optineuron in 100ml NS over 30 mins

IVF NS/RL at 150ml/hr

T. Paracetamol 650mg PO TID

SOAP NOTES DAY 4

S-C/o headache,neck pain subsided, no fever spikes today

O-

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

NO PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA, no petichiae

VITALS - 

TEMPERATURE - 96.9

PULSE RATE - 85 BPM

BLOOD PRESSURE - 

110/70 MM OF HG supine

110/70 mmHg standing

RESPIRATORY RATE - 19

SPO2 - 98 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

HEMOGRAM

HB 15.1

TLC 2900

PCV 45.2

MCV 80.9 

Plt 41,000

P. S NORMOCYTIC NORMOCHROMIC WITH neutropenia and thrombocytopenia

Platlet count

Day 1 - 92,000

Day 2 - 90,000

Day 3 - 50,000

Day 4 - 41,000

A-

viral pyrexia with thrombocytopenia with NS1POSITIVE

P-

Inj. Optineuron in 100ml NS over 30 mins

IVF NS/RL at 150ml/hr

T. Paracetamol 650mg PO TID