Case 8

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.



A 65 year old male is presented to OPD with chief complaints of fever and cough since 15 days and shortness of breath since 1 week.



HISTORY OF PRESENT ILLNESS-:

Daily routine(6 years back)

He used to wake up by  7am and was done with his breakfast by 9am then he used to feed his cattle and used to eat whenever he feels hungry and sleep at night by 9pm.


Daily routine(presently)

The Patient wakes up around 8 am and is done with his breakfast by 9am then he used to walk around in the house because he is not able to do any work properly due to blurring of vision, he will have his lunch by 1pm and dinner by 9pm then he used to take his medicines as the Patient said that he is not able to sleep without taking that medicines- Escitalopram and olanzepine.


Patient was apparently alright 6 years back then he developed instability in moods which was observed by his family members and they went to nearby hospital where doctor suggested CT scan and he was diagnosed with lacunar infarct in right thalamus and was on medication, again after 1 year he went for CT scan and he was diagnosed with small hypodense area seen in the right side of the thalamus.

After 3 years he was diagnosed with small hypodense area seen in the both thalamii and he also developed blurring of vision and undergone surgery of left eye due to which he lost his left eye vision completely and had blurring of vision in the right side.

He was admitted here 3 days back with chief complaint of fever and cough since 15 days and shortness of breath since 1 week.


HISTORY OF PAST ILLNESS-:

No history of hypertension, diabetes, asthma, tuberculosis 

Patient is on medication-Escitalopram and olanzepine since 2 years.


PERSONAL HISTORY-:

The patient has loss of appetite 

Sleep- inadequate 

Diet- mixed

Addictions- no


FAMILY HISTORY 

There is no similar complaints in the family members.


TREATMENT HISTORY 

Patient is on medication due to bordered personality disorder.


GENRAL EXAMINATION 

Patient is conscious,coherent and not co-operative at all.

There is no sign of icterus, cyanosis, clubbing, generalised  lymphadenopathy.



Right eye



Left eye








VITALS :

Temp :febrile 

Pulse rate:112bpm

Respiratory rate:22cpm

Bp:110/90 mm/hg

Spo2-98%

GRBS-110mg/dl


SYSTEMIC EXAMINATION:


CVS  :

No thrills 

No cardiac murmurs 

Cardiac sounds-S1,S2 heard 


RESPIRATORY SYSTEM :

INSPECTION 



PALPATION



PERCUSSION 



ASCULTATION


ABDOMEN:

Shape of abdomen-scaphoid 

No tenderness 

No palpable mass 

Hernial orifices-normal 

No free fluid 

No bruits 

Liver ,spleen-not palpable 

Bowel sounds -yes 


CNS:

Conscious 

speech is not proper

No neck stiffness 


INVESTIGATION 

23rd Nov
























24th Nov




26th Nov






Diagnosis- Pneumonia with Pancytopenia 

Acute kidney injury 

Anemia


TREATMENT 

22nd Nov

O2 supplementation if spo2<90%

Inj. Neomol 100ml/IV if temp>101degreeF 

Tab dolo 650mg /PO/BD

Syp Ascoryl 10ml /PO/BD

Neb with pravent and budecort

Inj Pan 40mg /IV/OD

Fever chart-4th hourly

Vital monitoring- hourly


23rd Nov

O2 supplementation if spo2<90%

Inj. Neomol 100ml/IV if temp>101degreeF 

Tab dolo 650mg /PO/BD

Syp Ascoryl 10ml /PO/BD

Neb with pravent and budecort

Inj Pan 40mg /IV/OD

Fever chart-4th hourly

Vital monitoring- hourly

W/f bleeding manifestation 

Inj ceftrioxone 1g IV/BD 


24th Nov

O2 supplementation if spo2<90%

Tab dolo 650mg /PO/BD

Syp Ascoryl 10ml /PO/BD

Neb with pravent and budecort

Inj Pan 40mg /IV/OD

Fever chart-4th hourly

Vital monitoring- hourly

Inj ceftrioxone 1g/IV/BD 

Tab Azithromycin 500mg/PO/OD 


25th Nov

O2 supplementation if spo2<90%

Tab dolo 500mg /PO/BD

Syp Ascoryl 10ml /PO/BD

Neb with pravent and budecort

Inj Pan 40mg /IV/OD

Fever chart-4th hourly

Vital monitoring- 2nd hourly

Tab Azithromycin 500mg/PO/OD 

Tab olzic 5mg


26th Nov

Tab dolo 500mg /PO/BD

Syp Ascoryl 10ml /PO/BD

Neb with pravent and budecort

Inj Pan 40mg /IV/OD

Fever chart-4th hourly

Vital monitoring- 2nd hourly

Tab Azithromycin 500mg/PO/OD 

Tab olzic 5mg


27th Nov

Inj Augmentin 1.2gm

Tab dolo 500mg /PO/BD

Syp Ascoryl 10ml /PO/BD

Neb with pravent and budecort

Tab pan 40mg PO/OD

Tab pragabaliw 75mg PO

Fever chart-4th hourly

Tab Azithromycin 500mg/PO/OD 

Tab olzic 5mg

Inform SOS



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