Dr Bhavya

80year old with fever ,burning micturition and dysphagia

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


80 year old female presented with the complains of fever since 3 months,

burning micturition since 3 months,

difficulty in swallowing since 1 month 


HISTORY OF PRESENT ILLNESS

Patient was apparently assymptomatic 3 months back then developed fever associated with burning micturition & abdominal pain for which she was brought to the hospital and was admitted (pyrexia of unknown origin) and was discharged on 25/10/22 post which she had no complaints till  19/11/22 , when patient had similar complaints and was treated at local hospital 

Previous record of hospital administration of patient 

https://nehareddygaddam.blogspot.com/2022/10/72-female-with-fever-burning.html?m=1


On 10/12/22 patient presented to our hospital with complaints of fever since 20 days associated with burning micturition 

Fever is low grade and continuous associated with chills & rigors , relieved partially with medication

K/c/o DM :20years on TAB.cinod T 

HTN :on Inj.HAI 8u-x-6u

Surgery: Right PFN 11yrs ago


PERSONAL HISTORY:

Decreased appetite takes mixed diet, irregular bowels( Type 1 Bristol stool) ,normal micturition , no allergies 


MENSTRUAL HISTORY:

Age of menarche - 15yrs

Menopause attained 30 years back


OBSTETRIC HISTORY:

Age at marriage-12yrs

Gravida 3 (all 3 are Full term NVD)

1st male , 2nd female - died

3rd - female alive 


GENERAL PHYSICAL EXAMINATION 

Patient conscious coherent cooperative 

Moderately built and nourished

Pallor present



No, icterus, cyanosis, clubbing, lymphadenopathy


Vitals

Bp:150/90mmhg

RR-20cpm

PR-98bpm

SPO2-94%

GRBS-343mg/dl (inj. HAI 14 units given)

TEMP-98.3F


SYSTEMIC EXAMINATION :

RESPIRATORY SYSTEM EXAMINATION-


Inspection

Drooping of right shoulder 

No engorged veins , discharging sinuses , scars

Apex beat cannot be seen

Trachea appears to be central  


Palpation

Inspectory findings are confirmed 

Trachea central

Decreased movements on right side 

Vocal fremitus more on right side 

Tactile fremitus more on right side 


Percussion

Dull note on right side


Auscultation

Inspiratory crepts in the right inframammary area 

Rest of the lung fields normal vesicular breath sounds 


CVS: S1 , S2 present

Pansystolic murmur present


CNS: NAD 


P/A: SOFT, TENDER


PROVISIONAL DIAGNOSIS:  

PYREXIA OF UNKNOWN ORIGIN WITH ? PULM TB (ON ATT) ? CLINICAL MALARIA WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS WITH ANAEMIA (NORMOCYTIC NORMOCHROMIC) WITH CHOLELITHIASIS


INVESTIGATIONS:

REPORTS-


Fever chart



2D Echo


ECG

Bacteria and culture sensitivity

USC Abdomen


USG Neck

X ray Neck

Chest x ray



HRCT Chest


HRCT CHEST Report




REFERRALS: 

                  CARDIOLOGY REFERRAL


                        Surgery referral



                               ENT referral



                     PULMONOLOGY Referral


                         DVL referral




 TREATMENT: 

10/12/22


Patient presented with complaint of fever since 3 months on and off, difficulty in swallowing since 1 month


S

Fever 


O

Pt is C/C/C

BP:110/70mmHg

PR:82bpm

RR:24cpm

SpO2:95% on RA

Temp :101 F

CVS:S1S2 +

RS :BAE +

PA-soft no organomegaly


A

PYREXIA UNDER EVALUATION 


P

INJ. PIPTAZ 2.25 GM IV TID D7

INJ DOXY 100MG IV BD 

INJ PAN 40MG IV OD

INJ NEOMOL 1GM IV SOS 

TAB. DOLO 650 MG PO/TID

Vitals monitoring 4th hrly 

GRBS monitoring 6th hrly


11/12/22


Patient presented with complaint of fever since 3 months on and off, difficulty in swallowing since 1 month


S

2 fever spikes @ 2:00 pm- 101f 

@10pm - 102f



P

INJ. PIPTAZ 2.25 GM IV TID D7

INJ DOXY 100MG IV BD 

INJ PAN 40MG IV OD

INJ NEOMOL 1GM IV SOS 

TAB. ATT  3 TABLETS /DAY

TAB. CINOD T PO/OD 

INJ. HAI ACCORDING TO GRBS- S/C

TAB. BENADON 40 MG PO/OD

INJ.FALCIGO 120mg IV/0th hr-12th hr-24th hr-48th hr

Tab NICARDIA 10mg PO/OD 

Vitals monitoring 4th hrly 

GRBS monitoring 6th hrly


13/12/22


Patient presented with complaint of fever since 3 months on and off, difficulty in swallowing since 1 month


S

1fever spike at 8:00 am- 101f  and difficulty in swallowing 



O

Pt is C/C/C

BP:160/90mmHg

PR:76bpm

RR:26cpm

SpO2:95% on RA

Temp :afebrile

CVS:S1S2 +

RS :BAE +

PA-soft no organomegaly




Temp :afebrile


CVS:S1S2 +


RS :BAE +


PA-soft no organomegaly


A


PYREXIA OF UNKNOWN ORIGIN WITH ? PULM TB ? CLINICAL MALARIA WITH HTN SINCE 20 YRS , TYPE II DM SINCE 20 YRS WITH ANAEMIA SECONDARY TO BLOOD LOSS OR NUTRITIONAL WITH CHRONIC CONSTIPATION(NORMOCYTIC NORMOCHROMIC) WITH CHOLELITHIASIS 




P 

TAB CINOD PO/BD


TAB MET- XL 25 MG PO/OD


TAB NICARDIA 10mg PO/SOS


TAB ULTRACET 1/2  tab PO/QID


Vitals monitoring 4th hrly 


GRBS monitoring 6th hrly


Plan for HRCT  and to withhold ATT today


18/12/22



P 


TAB TELMA 40mg PO/OD 


TAB METXL 25mg PO/OD


TAB AMLONG 5mg PO/OD 


TAB NICARDIA 10mg PO/SOS


INJ HAI 4-4-4


INJ NPH 4-x-4


Vitals monitoring 4th hrly 


GRBS monitoring 7th hrly 


HRCT was done yesterday 

Inference - 

1) non resolving consolidation

2) Bronchoalveolar carcinoma


Planning for Usg guided biopsy & aspiration today


Patient was referred to higher center on 20/12/22


Follow up-

Upon referral patient was taken to another esteemed hospital where the necessary investigations were done and these are the reports:


















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