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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competence in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan
CHEIF COMPLAINTS:
Fever since 10 days
Burning micturition since 1 day
Left loin pain since 1 day
Decreased urine output since 1day
Blood in urine since 3 hrs
HISTORY OF PRESENTING ILLNESS
A 80Yr male, agriculture by occupation,clinically presented to casualty with complaints of high grade fever since 10 days (25th sep - 5th oct) , not associated with cold / cough/abdominal pain.which was releived on taking antipyretics and oral antibiotics . Afterday10 of illness his fever subsided . After 3 days i.e he had symptoms of burning micturition, abdominal distention and left loin pain , non radiating, dragging type and decreased urine output having dark yellowish coloured urine since 1 day.
PAST ILLNESS:
K/c/o : Hypertension since 1yr and taking medications irregularly
Right lower end of tibial fracture 1 yr ago
Not a K/c/o TB/asthma/CAD/CVD/epilepsy/ thyroid disorders
PERSONAL HISTORY:
80Yr male, married , agriculture by occupation, has normal appetite, mixed diet , regular bowels( not passed stools today), decreased urine output,no allergies, occasionally drinks ( once in a week) I.e (3.6 units of alcohol/week)
Smokes 10beedi/day (30 pack years)
No significant Family history
ON GENERAL PHYSICAL EXAMINATION
Patient was drowsy , incoherent
GCS - E2( eye opening to pain)
V2( verbal response- volcalises i.e makes sounds but no word)
M3( motor response I.e abnormal flex
ion to pain)
pallor present
No icterus , cyanosis , clubbing, lymphadenopathy,edema
VITALS:
On presentation
Temp.-99.7
Bp- 120/90mmhg
PR-98bpm
RR-18cpm
Grbs-116mg/dl
SYSTEMIC EXAMINATIONS
CVS: S1s2 heard
R/S : BAE+ ,
right infraxillary area crepts +
decreased breath sounds,
P/A :scaphoid ,soft ,tenderness at umbilicus ,bowel sounds heard, stools passed yesterday
COURSE IN HOSPITAL
A 80Yr male came to casualty with above mentioned complaints. Upon arrival initial assessment was done. He was started on intravenous fluid therapy. Urine analysis and culture and sensitivity were sent . Urine analysis showed 10-1
febrile to touch
GCS : E4V5M6
PR:142bpm
Bp:110/70mmhg
RR:18cpm
Pleural tap was done on 15/10/22
X-ray after pleural tap
TREATMENT:
1.IVF 3% NS @ 75ml/hr
2.INJ.MEROPENEM 500mg /IV /Bd for7 days
3. INJ.PAN40mg /iv/bd
4.inj. Tramadol 1Amp in 100ml Ns/iv/od
5.inj. NEOMOL 1gm
6. Tab.dolo 650 mg/po/TID
7. Ryles tube insertion
8. Tab. Azithromycin 500mg /po/od for 6 days
9. Inj. Vancomycin 1gm /iv/bd for 4 days
1st,3rd
2nd,4th 
X-ray on 16/10/22
Chest X-ray PA VIEW SUPINE POSITION TAKEN ON 17/10/22
Pleural fluid(EXUDATE)
Pleural fluid analysis- EXUDATE
Day 8
2nd time Pleural tap was done on 18/10/22
X-ray after pleural tap(2nd)
Patient developed pneumothorax
Then after taking consent an ICD is placed in 5th ICS in mid axillary line
Fluid collected through ICD
( transudate)
Pleural fluid analysis:
Transudate
USG abdomen was done on 18/10/22
Ascitic Tap (diagnostic)was done on18/10/22
And sent for cytology, culture sensitivity, cell count
Day :9
S : PAIN at site of ICD insertion, fever spike -yesterday 8pm
O:
Pt c/c/c
Bp - 110/70mmhg
PR - 110bpm
RR- 22cpm
Temp-98F
Spo2 - 92 at room air
CVS: S1S2+ loud s1@ aortic and pulmonary area
apex beat at left 5th intercoastal space extended lateral to MCL
RS: BAE+
Inspection: Respiratory movements slightly more on right compared to left chest
Crowding of ribs present
ICD- @ 5th Intercostal space @ mid axillary line
CREPTS AT
LEFT INFRAAXILLARY AREA, IMA,ISA
RIGHT ISA,IMA
P/A: SOFT,BS+,Tenderness on palpation around umbilicus , stools not passed-D1
CNS: HMF INTACT
NO FND
Input : 2300ml
Output: 1200ml
DIAGNOSIS:
ALTERED SENSORIUM SECONDARY TO ?HYPONATREMIA (resolved)-
WITH CAP (RIGHT UL ANT LEFT LUNG)
? SEPTIC ENCEPHALOPATHY -LEFT PYELONEPHRITIS ( resolving)
WITH PRE RENAL AKI
with MICROCYTIC HYPOCROMIC ANEMIA SECONDARY TO ?IRON DEFICIENCY
? ANEMIA OF CHRONIC DISEASE
WITH LEFT EMPYEMA
WITH PNEUMOTHORAX WITH ICD DAY1
with k/c/o COPD and HTN
Treatment
1)ALLOW ORAL FEEDS
2)IVF -NS/RL @50ml/hr
3) TAB. MIRTRAZAPINE 7.5mg/PO/HS
4)INJ. MEROPENEM 500 MG IV/BD (D10)
5) INJ. PAN 40MG IV/OD
6) INJ. TRAMADOL 1 AMP IN 100ML NS/IV/OD
7) INJ. VANCOMYCIN 1Gm/IV/BD(D7)
8) TAB. DOLO 650MG PO/ TID If temp.> 100F
9) NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY
10)VITAL + I/O CHARTING HOURLY
11)ICD care
bag always below waist
Cap always open
Check air coloum movement
Maintain under water seal
12)O2 inhalation with 2-4 lit
- Syp . POTCLOR 10ml in glass of water.
20/10/22
ICU BED NO.6!
Day :11
S : abdominal pain
O:
Pt c/c/c
Bp - 120/70mmhg
PR - 112bpm
RR- 23cpm
Temp-100F
Spo2 - 90at room air ; 97% with 2lit O2
CVS: S1S2+ loud s1@ aortic and pulmonary area
apex beat at left 5th intercoastal space extended lateral to MCL
RS: BAE+
Inspection: Respiratory movements slightly more on right compared to left chest
Auscultation:CREPTS AT
LEFT INFRAAXILLARY AREA, IMA,ISA
RIGHT ISA,IAA
P/A: scaphoid , SOFT,BS+,Tenderness ++ diffuse
CNS: HMF INTACT
NO FND
Input : 1175ml
Output: 990ml
A
ALTERED SENSORIUM SECONDARY TO ?HYPONATREMIA (resolved)-
WITH CAP (RIGHT UL ANT LEFT LUNG) SECONDARY TO KLEBSIELLA PNEUMONIA
SPONTANEOUS BACTERIAL PERITONITIS -LEFT PYELONEPHRITIS WITH PRE RENAL AKI ( resolving)
WITH RIGHT HEART FAILURE SECONDARY TO CORPULMONALE
with MICROCYTIC HYPOCROMIC ANEMIA SECONDARY TO ?IRON DEFICIENCY
? ANEMIA OF CHRONIC DISEASE
WITH LEFT EMPYEMA
WITH PNEUMOTHORAX WITH ICD DAY3
with k/c/o COPD and HTN
P
*
INJ. COLISTNMETHATE SODIUM 4.5 MIU./. Iv/OD/OVER 30MIN in100ML NS (DAY3)
Ambulization , wheel chair mobilization
21/10/22
21/10/22
AMC BED NO. I
Day :12
S : Diffuse abdominal pain
O:
Pt c/c/c
Bp - 110/70mmhg
PR - 21bpm
RR- 21cpm
Temp-98.7F
Spo2 - 97at room air
CVS: S1S2+ loud s1@ aortic and pulmonary area
apex beat at left 5th intercoastal space extended lateral to MCL
RS: BAE+
Inspection: Respiratory movements slightly more on right compared to left chest
On percussion: left4th,5th ICS - dull
Auscultation:decreased breath sounds at IMA,ISA
CREPTS AT
LEFT INFRAAXILLARY AREA, IMA,ISA
RIGHT IAA
P/A: scaphoid , SOFT,BS+,Tenderness + bowel sounds sluggish
CNS: HMF INTACT
NO FND
Input : 975ml
Output: 1200ml
A
ALTERED SENSORIUM SECONDARY TO ?HYPONATREMIA (resolved)-
WITH CAP (RIGHT UL ANT LEFT LUNG) SECONDARY TO KLEBSIELLA PNEUMONIA
SPONTANEOUS BACTERIAL PERITONITIS -LEFT HYDROURETERO NEHROSIS
WITH PRE RENAL AKI ( resolving)
WITH RIGHT HEART FAILURE SECONDARY TO CORPULMONALE
with MICROCYTIC HYPOCROMIC ANEMIA SECONDARY TO ?IRON DEFICIENCY
? ANEMIA OF CHRONIC DISEASE
WITH LEFT EMPYEMA
WITH PNEUMOTHORAX WITH ICD DAY4
WITH GRADE I BED SORE
with k/c/o COPD and HTN
P
1. NBM TILL FURTHER ORDERS (I/v/o diffuse abdominal pain, bowel wall edema)
2)IVF -NS/RL @50ml/hr
3) PROTIEN X- powder 2 scoops + 100ml milk
4) BUSCOPAN 20MG/IM/SOS
5) INJ. PAN 40MG IV/OD
6) TAB. MITRAZAPINE 7.5Mg po/Hs
8) TAB. DOLO 650MG PO/ TID If temp.> 100F
9) NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY
10)VITAL + I/O CHARTING HOURLY
11)ICD care
bag always below waist
Cap always open
Check air coloum movement
Maintain under water seal
12)O2 inhalation with 2-4 lit
13. Ambulation, wheel chair mobilization
* . COLISTNMETHATE SODIUM
CBNAAT showed Tuberculosis positive, sensitive to rifampicin
22/10/22
AMC BED NO. 1
Day :13
80/Male
S : Decrease appetite
loose stools since Yesterday (5episodes)
O:
Pt c/c/c
Bp - 110/70mmhg
PR - 124bpm
RR- 19cpm
Temp-101F
Spo2 - 96at room air
CVS: S1S2+ loud s1@ aortic and pulmonary area
apex beat at left 5th intercoastal space extended lateral to MCL
RS: BAE+
Inspection: Respiratory movements slightly more on right compared to left chest
On percussion: left4th,5th ,6th ICS - dull
Auscultation:decreased breath sounds at IMA,ISA
CREPTS AT
LEFT INFRAAXILLARY AREA, IMA,ISA
RIGHT IAA CREPTS
P/A: scaphoid , SOFT,BS+,Tenderness + ,bowel sounds+
CNS: HMF INTACT
NO FND
Input : 975ml
Output: 1200ml
A
ALTERED SENSORIUM SECONDARY TO ?HYPONATREMIA (resolved)-
WITH CAP (RIGHT UL ANT LEFT LUNG) SECONDARY TO KLEBSIELLA PNEUMONIA
SPONTANEOUS BACTERIAL PERITONITIS -LEFT HYDROURETERO NEHROSIS
WITH NON OLIGURIC AKI
WITH RIGHT HEART FAILURE SECONDARY TO CORPULMONALE
with MICROCYTIC HYPOCROMIC ANEMIA SECONDARY TO ?IRON DEFICIENCY
? ANEMIA OF CHRONIC DISEASE
WITH LEFT EMPYEMA
WITH GRADE I BED SORE
PULMONARY TUBERCULOSIS
with k/c/o COPD and HTN
P
1. Allow oral fluids 2lit/day
2)IVF -NS/RL with optineuron @50ml/hr
3) Tab. SPOROLAC po/sos
4) BUSCOPAN 20MG/IM/SOS
5) INJ. PAN 40MG IV/OD
6) TAB. MITRAZAPINE 7.5Mg po/Hs
8) TAB. DOLO 650MG PO/ TID If temp.> 100F
9) NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY
10)VITAL + I/O CHARTING HOURLY
12)O2 inhalation with 2-4 lit
13. Ambularono , wheel chair mobilization
14. PROTIEN X- powder 2 scoops + 100ml milk
15. ATT.—TAB. Isoniazide 215mg/po/od ,
16. Tab. RIFAMPICIN 430mg/po/od
17. Tab.pyrizinamide 1125mg/po/od
18. Tab.Ethambutol 540mg/po/od
25/10/22
Day :16
S : pruritis, no fever spike , Right hypochondriac pain
O:
Pt c/c/c
Bp - 110/80mmhg
PR - 120pm
RR-24cpm
Spo2 - 96%at room air
CVS: S1S2+ loud s1@ aortic and pulmonary area
apex beat at left 5th intercoastal space extended lateral to MCL
Parasternal heave +
RS: BAE+
On percussion: less resonant on left side
Auscultation: BAE+ no abnormal sounds heard
P/A: scaphoid , SOFT,BS+,Tender right hypocondrium ,4episodes of stools
CNS: HMF INTACT
NO FND
Input : 2900ml
Output: 2050ml
A
PULMONARY TUBERCULOSIS on ATT( Started on 22/10/22)
Left CAP secondary to klebsiella pneumonia with left pneumothorax (resolved)
With left hydrouretronephrosis
With non oliguric AKI
With culture negative neutrocytic ascitis
With right heart failure secondary to
Cor-Pulmonale
With COPD with Hyponatremia (resolved)
With k/c/o HTN with grade 1 bed sore
P
1. Allow oral fluids 2lit/day
2.IVF -NS/RL @50ml/hr
3.BUSCOPAN 20MG/IM/SOS
4.INJ. PAN 40MG IV/OD
5.TAB. MITRAZAPINE 7.5Mg po/Hs
6.TAB. DOLO 650MG PO/ TID If temp.> 100F
7.NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY
8.VITAL + I/O CHARTING HOURLY
9.cap. Kedotil 100mg/po/sos(if loose stools+)
10. Ambulation,wheel chair mobilization
11.PROTIEN X- powder 2 scoops + 100ml milk 12.ATT.(day4)
TAB. Isoniazide 300mg/po/od ,
Tab. RIFAMPICIN 450mg /po/od
13.Tab. Benadone 40mg/po/od
14.Inj.Zofer 4mg /iv/sos
25/10/22
Day :16
S : pruritis, no fever spike , Right hypochondriac pain
O:
Pt c/c/c
Bp - 110/80mmhg
PR - 120pm
RR-24cpm
Spo2 - 96%at room air
CVS: S1S2+ loud s1@ aortic and pulmonary area
apex beat at left 5th intercoastal space extended lateral to MCL
Parasternal heave +
RS: BAE+
On percussion: less resonant on left side
Auscultation: BAE+ no abnormal sounds heard
P/A: scaphoid , SOFT,BS+,Tender right hypocondrium ,4episodes of stools
CNS: HMF INTACT
NO FND
Input : 2900ml
Output: 2050ml
A
PULMONARY TUBERCULOSIS on ATT( Started on 22/10/22)
Left CAP secondary to klebsiella pneumonia with left pneumothorax (resolved)
With left hydrouretronephrosis
With non oliguric AKI
With culture negative neutrocytic ascitis
With right heart failure secondary to
Cor-Pulmonale
With COPD with Hyponatremia (resolved)
With k/c/o HTN with grade 1 bed sore
P
1. Allow oral fluids 2lit/day
2.IVF -NS/RL @50ml/hr
3.BUSCOPAN 20MG/IM/SOS
4.INJ. PAN 40MG IV/OD
5.TAB. MITRAZAPINE 7.5Mg po/Hs
6.TAB. DOLO 650MG PO/ TID If temp.> 100F
7.NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY
8.VITAL + I/O CHARTING HOURLY
9.cap. Kedotil 100mg/po/sos(if loose stools+)
10. Ambulation,wheel chair mobilization
11.PROTIEN X- powder 2 scoops + 100ml milk 12.ATT.(day4)
TAB. Isoniazide 300mg/po/od ,
Tab. RIFAMPICIN 450mg /po/od
13.Tab. Benadone 40mg/po/od
14.Inj.Zofer 4mg /iv/sos
https://nehareddygaddam.blogspot.com/2022/10/80yr-male-with-altered-sensorium.html
26/10/22
Day :17
S : pruritis, no fever spike , Right hypochondriac pain, loose stools(?antibiotic induced?)
O:
Pt c/c/c
Bp - 110/60mmhg
PR - 136pm
RR-26cpm
Spo2 - 97%at room air
CVS: S1S2+ loud s1@ aortic and pulmonary area
apex beat at left 5th intercoastal space extended lateral to MCL
Parasternal heave +
RS: BAE+
On percussion: less resonant on left side
Auscultation: BAE+ no abnormal sounds heard,decreased breath sounds in IAA,IMA
P/A: scaphoid , SOFT,BS+,Tender right hypocondrium ,episodes of loose stools
CNS: HMF INTACT
NO FND
Input : 2500ml
Output: 2000ml
A
PULMONARY TUBERCULOSIS on ATT( Started on 22/10/22)
Left CAP secondary to
klebsiella pneumonia superinfection
with left pneumothorax (resolved)
With left hydrouretronephrosis
With non oliguric AKI
With culture negative neutrocytic ascitis
With right heart failure secondary to
Cor-Pulmonale
With COPD with Hyponatremia (resolved)
With k/c/o HTN with grade 1 bed sore
P
- Allow oral fluids 2lit/day
3.BUSCOPAN 20MG/IM/SOS
4.INJ. PAN 40MG IV/OD
5.TAB. MITRAZAPINE 7.5Mg po/Hs
6.TAB. DOLO 650MG PO/ TID If temp.> 100F
7.NEB WITH DUOLIN 6th HOURLY and BUDECORT 8tH HOURLY
8.VITAL + I/O CHARTING HOURLY
9.cap. Kedotil 100mg/po/sos(if loose stools+)
- Ambulation,wheel chair mobilization
11.PROTIEN X- powder 2 scoops + 100ml milk 12.ATT.(day5)
TAB. Isoniazide 300mg/po/od ,
Tab. RIFAMPICIN 450mg /po/od
TAB.Pyrazinamide 1500mg/po/od
TAB. Ethambutol 400mg /po/od
13.Tab. Benadone 40mg/po/od
14.Inj.Zofer 4mg /iv/sos
80 year male clinically presented with above mentioned complaints. Upon admission chest x ray was done which showed pneumothorax, for which pulmonology refferal was taken for emergency needle decompression and tube thoroacostomy. Under asceptic conditions ICD tube was placed at left 5th ICS at mid axillary line, and ICD tube was connected to underwater seal. USG Abdomen showed Ascites with septae and ascitic tap was done and sent for culture Pleural fluid was sent for CBNAAT and pleural analysis.
pleural fluid culture and sensitivity showed growth of Klebsiella pneumonia which was resistent to Meropenem, so patient was started on Colistin for 3 days.Pleural fluid analysis for CBNAAT showed Positive for Mycobacterium tuberculosis and sensitive to Rifampacin. His serum creatinine was 2.5 mg/dl and was started on ATT at renal modified doses from 22/10/2022.
2d echo was done on 19/10/2022 which showed e/o
No RWMA; Mild LVH; Mild to Moderate TR with PAH; Sclerotic AV; EF 58%; Diastolic dysfunction.
During hospital stay patient was treated with antitubercular drug, Intravenous antibiotics and other supportive medications. Their is clinical improvement of the patient.
On serial chest x ray their is improvement in the left lung consolidation. His Sr.creatinine was in increasing trend, so pulmonology cross consultation was taken, the pulmonologist was advised to stop pyrazinamide and Ethambutol. The patient condition has been improved, so being discharged in a hemodynamically stable condition.
Psychiatry cross consultation was taken in view of tobacco craving and advise followed
Review in Pulmonology OPD after 3 days .
EXTRAPULMONARY TUBERCULOSIS;
LEFT CAP SECONDARY TO KLEBSIELLA PNEUMONIA ( SUPERINFECTION);
LEFT PNEUMOTHORAX ( RESOLVED);
CULTURE NEGATIVE NEUTROCYTIC ASCITES;
DRUG INDUCED NON OLIGURIC AKI;
HEART FAILURE SECONDARY TO CORPULMONALE WITH COPD;
HYPONATREMIA (RESOLVED); K/C/O HTN.
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