68 yr old male with intermittent fever

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Name : SANTOSH KUMAR .K ( Intern ) 

Roll Number : 62

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. 

CHEIF COMPLAINTS:

A 67 YEAR OLD MALE PATIENT CAME TO OPD WITH CHEIF COMPLAINTS OF FEVER ON AND OFF SINCE 1MONTH.

LOSS OF APPETITE SINCE 15-20 DAYS.

HOPI:

PATIENT WAS APPARENTLY NORMAL 1 MONTH BACK.HE THEN HAD FEVER WHICH WAS LOW GRADE,INTERMITTENT, RELIEVED BY MEDICATION,NOT ASSOCIATED WITH CHILLS AND RIGOURS.NO COLD/COUGH/PAIN ABDOMEN/BURNING MICTURITION.

H/O SOB ON WALKING,NO SOB ON SITTING /RESTING STATE.RELIEVED BY TAKING REST 

H/O LOSS OF APPETITE SINCE 15-20 DAYS.

PATIENT ALSO GIVES H/O GIDDINESS,BLACK COLOURED STOOLS(SINCE 2 DAYS)

HISTORY OF PAST ILLNESS:

K/C/O DMT2 ON MEDICATION SINCE 10 YEARS

USING GLUCONORM-M1-BD

NOT A K/C/O HTN/TB/EPILESPY/ASTHMA/CVA/CAD.

SURGICAL HISTORY:

OPERATED FOR INGUINAL HERINA 10-15 YEARS BACK.

PERSONAL HISTORY:

DIET:MIXED

APPETITE:LOST SINCE 15 DAYS

 BLADDER MOVEMENTS Regular

Bowel movements irregular

HABITS: ALCOHOL -OCCASIONAL-STOPPED 3 YEARS BACK.

FAMILY HISTORY:

NO SIGNIFICANT FAMILY HISTORY.

GENERAL PHYSICAL EXAMINATION:

ON EXAMINATION PATIENT IS ORIENTED TO TIME ,PLACE,PERSON.

PALLOR-PRESENT

NO ICTERUS, CYNOSIS,CLUBBING,LYMPHADENOPATHY.

Edema seen pitting type  seen just above ankles

VITALS:

TEMP-98.4F

PR-98BPM

RR-22CPM

BP-130/70MMHG.

SYSTEMIC EXAMINATION:

CVS:S1S2 HEARD,NO MURMURS.

RS:BAE PRESENT,DYSPNOEA ON EXERTION,WHEEZE ABSENT.

P/A:SOFT,NON TENDER.

CNS:HMF intact

DIAGNOSIS 

ANEMIA UNDER EVALUATION SECONDARY TO ? GI blood loss associated with infection

K/C/O DIABETIC NEPHROPATHY SINCE 2 YEARS 

K/C/O OSA SINCE 3 YEARS (ON INTERMITTENT CPAP)

INVESTIGATIONS:

ECG 

USG 

No sonological abnormalities seen in abdomen

2D ECHO 

EF 58% 

RVSP  48 MM HG 

MILD AR +VE

TR+ VE 

TRIVIAL MR + VE 

NO RWMA 

NO AS/MS  SLEROTIC AV

GOOD LV SYSTOLIC FUNCTION 

SIASTOLIC DYSFUNCTION POSITIVE 

CHEST X RAY PA VIEW 

PERIPHERAL SMEAR 

RBC NORMOCYTIC NORMOCHROMIC  WITH MICROCYTED AND TEAR DROP 

WBC. WITH IN NORMAL LIMITS 

PLATELET. IN ADEQUATE NUMBER 

SLEEP STUDY 

DONE BY  K MEDHA  REDDY  INTERN

Stools on 3/2/23

Endoscopy of this pt for any upper gi bleed

https://youtu.be/tfKiFWgepxc

It's shown erosive pangstritis findings but no active bleed

TREATMENT:

1.PANTOPRAZOLE 4MG/IV/OD

2.INJ.OPTINEURON 1AMP IN 100ML NS IV/OD/OVER 45 MINS

3.INJ.NEOMOL 1GM IV/SOS (IF TEMP>101F)

4.INJ.HAI S/C ACC TO GRBS 

8AM-2PM-8PM

5.TAB DOLO 650MG PO/SOS

6.GRBS 6TH HRLY

7.I/O CHARTING

8.SYP.ARISTROZYME 30ML/PO/TID

9.TEMP CHARTING 4TH HOURLY

10.MONITOR VITALS

Day 1

65 yr old male 

ICU

S

Stools not passed 

Appetite decreased 

 O

Pt is c/c/c

TEMP- afebrile

PR-98BPM

RR-18 CPM

BP-110/70MMHG.

Grbs 120 mg/dl

CVS:S1S2 HEARD,NO MURMURS.

RS:BAE PRESENT NVBS

P/A:SOFT,NON TENDER.

CNS:HMF PRESENT.

A

ANEMIA UNDER EVALUATION. ? ACUTE HEMOLYSIS SECONDARY TO INFECTION K/C/O TYPE 2 DM SINCE 10 YRS K/C/O DIABETIC NEUROPATHY SINCE 2 YRS K/C/O OSA SINCE 3 YRS.

P 

1 INJ .PANTOPRAZOLE 4O MG/IV/OD

2.INJ.OPTINEURON 1AMP IN 100ML NS IV/OD/OVER 1 HR

3.INJ.NEOMOL 1GM IV/SOS (IF TEMP>101F)

4.INJ.HAI S/C ACC TO GRBS 

5.TAB DOLO 650MG PO/SOS

6.GRBS 6TH HRLY

7.I/O CHARTING .

8.SYP.ARISTROZYME 30ML/PO/TID

9.TEMP CHARTING 4TH HOURLY

10.MONITOR VITALS

Urine sample day 1

Day 2

65 yr old male 

ICU

S

Stools not passed 

Afebrile 

1 fever spike at 7 pm 

Appetite decreased 

 O

Pt is c/c/c

TEMP- afebrile

PR-98BPM

RR-18 CPM

BP-110/70MMHG.

Grbs 120 mg/dl 6 u HAI given

CVS:S1S2 HEARD,NO MURMURS.

RS:BAE PRESENT NVBS

P/A:SOFT,NON TENDER.

CNS:HMF PRESENT.

A

ANEMIA UNDER EVALUATION. ? ACUTE HEMOLYSIS SECONDARY TO INFECTION K/C/O TYPE 2 DM SINCE 10 YRS K/C/O DIABETIC NEUROPATHY SINCE 2 YRS K/C/O OSA SINCE 3 YRS.

P 

1 INJ .PANTOPRAZOLE 4O MG/IV/OD

2.INJ.OPTINEURON 1AMP IN 100ML NS IV/OD/OVER 1 HR

3.INJ.NEOMOL 1GM IV/SOS (IF TEMP>101F)

4.INJ.HAI S/C ACC TO GRBS 

5.TAB DOLO 650MG PO/SOS

6.GRBS 6TH HRLY

7.I/O CHARTING .

8.SYP.ARISTROZYME 30ML/PO/TID

9.TEMP CHARTING 4TH HOURLY

10.MONITOR VITALS

Urine sample day 2

Day 3 

65 yr old male 

ICU

S

Black colour Stools passed

Yesterday 1 fever spike 

Appetite decreased 

 O

Pt is c/c/c

PR-98BPM

RR-18 CPM

BP-110/60MMHG.

Grbs 145 mg/dl 

I/O. 750 ml / 1000 ml 

CVS:S1S2 HEARD,NO MURMURS.

RS:BAE PRESENT NVBS

P/A:SOFT,NON TENDER.

CNS:HMF INTACT

A

ANEMIA UNDER EVALUATION. SECONDARY ? GI blood losses K/C/O TYPE 2 DM SINCE 10 YRS K/C/O DIABETIC NEPHROPATHY SINCE 2 YRS K/C/O OSA SINCE 3 YRS.( ON CPAP).

1 UNIT PRBC TRANSFUSION DONE YESTERDAY

P 

1 INJ .PANTOPRAZOLE 4O MG/IV/OD

2.INJ.OPTINEURON 1AMP IN 100ML NS IV/OD/OVER 1 HR

3.InJ MONOCEF 1 GM /IV/BD

4.INJ.HAI S/C ACC TO GRBS 

5.TAB DOLO 650MG PO/SOS

6.GRBS 7 .0 PROFILE MONITORING 

7.I/O CHARTING AND MONITORING VITALS 

8.SYP.ARISTROZYME 30ML/PO/TID

9.TEMP CHARTING 4TH HOURLY

10.SYP CREMAFFIN 15 ML PO/ BD .

Urine sample on day 3

Question 

1) what is reason for intermittent hematuria?

2) is there another reason for blood loss other then urine

3) what the reason for his fever is there any associated infection cause?