67yr male with fever and generalized weakness

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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

CHIEF COMPLAINTS 

Fever since 10days

Dry cough since 10days 

Generalized weakness and bodypains since 10days 

Decreased appetite since 5 days 

Red colored urine since 5 days 

Vomiting on Day 4 of illness

Pain abdomen since 2 days

HISTORY OF PRESENTING ILLNESS

A67 year male,milkman by occupation, came to casualty with complaints of fever associated with chills with evening rise in temperature, associated with dry cough, which was more in the evening , not associated with positional change . History of vomiting food as it’s content , non bilious,non projectile. History of decreased appetite since 5 days . History of reddish colored urine passage , not associated with burning /pain during micturation . History of breathlessness on exertion during episodes of fever . History of epigastric pain , squeezing & burning type ,if he doesn’t have food

HISTORY OF PAST ILLNESS 

In 2007 September, he had c/o hemoptysis( aortic dissection) slurring of speech (right MCA infarct) and right loin pain (staghorn calculus, underwent ESWL)

K/c:o Hypertension since 15 yrs and on atenolol 50mg

  

History of surgeries: CAG+ CABG + Aortic flap  surgery, ESWL

 

PERSONAL HISTORY

67yr male, married ,Buffalo milking by occupation, with decreased appetite, non vegetarian,regular bowel moments,abnormal micturition ( red colour urine), occasionally drinks alcohol since 2 yrs once in 6months (4times /year) 

FAMILY HISTORY - not significant

GENERAL PHYSICAL EXAMINATION 

Patient was conscious , coherent , cooperative

No pallor

Febrile- 104.1

Bp- 90/60mmhg

PR-102bpm

RR- 32cpm

 COURSE IN HOSPITAL:

A 47 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 analysis10-15, PH:negative for ketones. The patient has been shifted to AMC . 

Hb:11.4gm/dl,TLC:11,000cells/mm3,Blood Urea: 45,serum creatinine 1.0.serum sodium:133, serum k+ 4.4, APTT:48sec,PT:25sec urinary calcium- 7.3

On 12/10/22 Hb:9.7, TLC: 18,900 APTT:17sec, INR: 1.2sec

USG abdomen was done on 10/10/22

Liver: normal size 

Pancreas : normal size 

Spleen : 10.3 cm

Right kidney : 11.1 x 4.9 cm

Left kidney: 10.9 x 5.3 cm

Aorta, IVC : normal

No ascitis 

Impression: B/L GRADE I -II , RPD WITH LEFT RENAL CALCULUS

2D ECHO was done on 10/10/22

Mild TR with PAH

Trivial   AR +/MR +

Aorta -3.6cm

Aortic flow : 1.75

Pulmonary flow: 0.9

DYASTOLIC DYSFUNCTION +

TREATMENT GIVEN:

1. Intravenous fluids 75ml/hr
2. INJ.PAN 40mg IV/BD

    3. DOLO 650mg TID  for 5 DAYS

    4. VIT K 1 ampule FOR 3DAYS

  2nd day

    5. INJ. DOXY 100 mg IV/BD FOR 6DAYS

    6.INJ.PIPTAZ 4.5 gm IV TID  FOR 6DAYS

    7.THROMBOPHOBE OINTMENT