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Greetings to one and all who are currently reading my blog.  This is Jasmisri,third semester medical student

This is an online E - log book to discuss our patients 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 available 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-centered online portfolio and your valuable inputs on the comment box.


Note: This is an ongoing case and will be uploaded as and when information is provided. This E-Log has been made under the guidance of Dr. Roshini ma’am

Case:-

75 yr old male came to the casuality with c/o fever since 10 days,Altered sensorium since 6:00pm.

CHIEF COMPLAINTS:-
  • Fever since 10days
  • Altered sensorium since 6pm

HISTORY OF PRESENT ILLNESS:-

Patient was apparently alright till 10 days back then he had fever insidious onset, low grade Continous, Relieved on taking  medication, Not associated with chills  and Rigors.
Today morning patient was talking normally from 6 pm.patient was just muttering words. 

HISTORY OF PAST ILLNESS:-

Patient was farmer by occupation; one day 6 yrs back patient drank Alcohol, fell from cycle, got fractured in the Right Femur Neck fracture got treated from local RMP and was walking with support.
From 1 yr patient became more lethargic, Not interacting actively with the family members, spending more time on bed.
Bed Sores Over B/L back part of the legs

PAST HISTORY:-

No h/o similar complaints before.
No known comorbidities.

GENERAL EXAMINATION:-

  • No pallor
  • No icterus
  • No cyanosis
  • No clubbing
  • No lymphadenopathy
  • No edema.


Vitals:-
  • Temp- afebrile.
  • PR:96 BPM.
  • RR: 16 CPM.
  • Bp: 80/60 mm Hg
  • Spo2 : 98%
  • GRBS 196 MG%.
SYSTEMIC EXAMINATION:-

A. Cardiovascular system 
  • S1 S2 HEARD
  • NO MURMURS.
B. Respiratory system 
  • NVBS heard
  •  BAE +
  •  TRACHEA CENTRAL.
C. Per abdominal examination 
  • SOFT
  • NON TENDER
  • NON DISTENDED.
D. Central nervous system:-

1. Higher Mental Function:-

  • Drowsy but arousable
  • Oriented to person, place -, time -, Registration -, attention -, Recall -
  • Language - spontaneous speech , - fluency, - comprehension
2. Cranial nerves -
  •  all cranial nerves 
                               - gag reflex
                               -  vulva position

3. Motor system - attitude -
                                       Rt.              Lt.  
          
          •Tone.     UL
                         LL.       hypo
           
         •Power   UL
                         LL

        •Reflexes. B         +                 +
                          T
                          S
                          K
                          A
                     Plantars


4. Sensory system - Couldn't be done
                                     Deep pain +
                                     Sup pain +

5. Cerebellar system - couldn't be done
6. No signs of meningial irritation/ meningitis







INVESTIGATIONS:-


12/08/21

Hemogram report



Ultrasound report 


X-Ray

Urine analysis


Anti HCV antibodies


RFT



RTPCR



ESR


Urine test for ketone bodies


Complete urine examination 


Liver function test





Random blood sugar

 
ABG Report


2D Echo report:-

  • Good lv systolic potential + ( EF-58 percentage) 
  • No Rwma ,No ms /as
  • Mild Lvh + sclerotic av
  • Mild  mr+  trivial ar+
  • Diastolic dysfunction +
  • IVC dialated (1.45cms) normal
  •  No pe/lv clot

13/08/21

RFT


Hemogram report 


X-ray 





PSYCHIATRIC CROSS CONSULTATION:-

This is the case of 75yr old male diagnosed ?hyperglycemia,hypoalbuminenia,UTL,AKI,denovo DM2, With anemia and bed sores reffered i/v/o chronic illness which could be psychiatric manifestation as patient c/o  of pain and experiencing distress on excudation.

-- History noted from OD
--Patient is lying on bed  with Rt and IV cannuli responding with only on commands
--Unable to move both UL and LL


According to OD,
Patient was asymptomatic until 2months back when they observed patient having decreased interest in doing work and going out as he felt tried throught the day.But the patient was able to move walking stand and meet relatives and used to ask food and alcohol .Foot ulcers were seen  but patient has no complaints 

 OD demics any episodes of cryingspth, low mood, suizibility, loss of appetite, during this period. 

10 days back patient developed fever with tremors in hands and jaws and muttering of words due to pain with decreased interaction. Since 2days with ulcers on back so, they took him to local hospital and was treated later pt felt better able to speak properly and ate food.
After 4 days patient has similar episodes with fever and was brought to KIMS. 


H/o Alcohol use since 3 yrs, constipation since 2 months, 90ml (-3 units)  per week. 
Tobacco use since 30yrs( consumes 10-15 beedis per day)
H/o disinhibited behaviour since 2 months.
H/o fall from cycle ? decreased alcohol and suffered # of hip/femur right side didn't visit hospital had local treatment since then staying  at home and stopped field work. 
Patient was able to do his daily activities can also used to ride cycle occasionally.
No h/o self talking, self laughing, suspicious memory disturbances, irritability, repitive thoughts. 
Not a known case of epilepsy, TB, asthama,HTN.

OD demics any psychiatc illness in family.
MSE :- Patient is lying on bed in upright position
ETEE -  , BILATERAL swelling of arms
PMA DECREASING
speech T,V,R DECREASING ,RT  INCREASING
--able to answer on repeated uestioning  by relatives
--mood and others MSC-CNB
--INFORMATION adjustment issue and *Alcohol dependence currently  ?  due to illness
*Tobacco dependence currently ? withdrawl


Rx-

  • patient attenders councelled
  • T.SERTA 25 mg 1-x-x
  • losenges 2mg six 





PROVISINAL DIAGNOSIS:-

  • Fever under evaluation
  • Altered sensorium
  • Hyperglycemia


TREATMENT:-

Day-1
  • INJ HAI IV  ( 39ml NS + HAI)@ 6ml/hr followed by infusion according to Alog-1
  • 1 hrly GRBS
  • INJ PIPTAZ 4.5gm IV stat followed by INJ PIPTAZ 2.25gm I've stat
  • INJ OPTINEURON 1 Amo in 100ml NS/IV/OD
  • Protein powder -2tsp in 1 glass of milk /twice a day
  • Rt feeds milk with protein powder - 100 my every 2 ND hrly and plain water every hrly.
  • Hrly GRBS charting 
  • INJ NORADRENALINE( 2amp in 50ml NS) @2ml /hr to maintain MAP >or = 6
Day -2

  • 1.IVF 10NS @75 ml/hr
  • 2.INJ PIPITAZ 2.25gm/IV/TID
  • 3.INJ OPTINEURON 1amp in 100ml NS
  • 4.TAB OROFER -XT/PO/OD
  • 5.TAB LASIX 20mg/PO/OD 
  • 6.Protein -x-powder -2tsp in 1 glass of milk /Rt feeds 2nd hrly
  •  Rt-plain water - 200ml /hrly
  • 7.INJ HALI /SC/TID 
  • 8.PR/BP/RR/SpO2 charting 2nd hourly
  • 9. GRBS charting 6th hourly
  • 10. Inj TRAMADOL 1 amp in 100 ml NS IV/OD
  • 11.TAB VITRACET 1/2 tab/RT
Day -3
  • 1. IVF NS @ 75ml/hr
  • 2. Inj PIPTAZ 2.25gm/IV/TID
  • 3. Inj Optineuron 1 amp in 100ml NS IV/OD
  • 4. Tab Orofer - XT/RT/OD
  • 5. Tab Lasix 20mg/RT/OD(if SBP > 100 mg 8am---- x ---- x
  • 6. Protein-X powder 2tsp in 1 glass of milk/ RT feed 2nd hourly
  • 7. Inj HAI/SC/TID after informing Sugars to ICU Ph
  • 8. Inj Tramadol 1 amp in 100 ml NS/IV/OD
  • 9. Tab Ultracet 1/2 tablet/RT/QID1/2----1/2----1/2----1/2
  • 10. Two egg whites/day
  • 11. Bp/PR/RR/SPO2 Charting 2nd hourly
  • 12. GRBS Charting 6th hourly 8am----2pm----8pm----2am
Day -4-

  • IVF 10 NS @75 ml/hr
  • Inj.Piptaj 2.25 gm/IV/T
  • Inj.Opti Neuron 1 amp in 100ml NS/N/OD
  • TAB.Fluconazole 150 mg/PO/OD
  • TAB. OROFER RT/OD
  • TAB.Lasix 20 mg/RT/OD
  • Protein-x powder 2 tbsp in 1 glass of milk,RT feed 2 nd hourly RT plain water-200 ml hourly
  • Inj.HAI /SC/TID 
  • Inj.TRAMADOL lamp in 100 pal NS/IV/OD
  • TAB.ULTRACET 1/2 tab/RT/OD 
  • 2 egg whites/day
  • BP/PR/RR/Spo2 charting 2nd hourly
  • GRBS charting 6th hourly 8 AM-2 PM-8 PM-2 AM

Day-5

  • IVF 10NS @75ml/hrly
  • INJ PIPTAZ 2.25 gm IV/TID
  • INJ OPTINEURON 1amp in 100 ml NS/ IV /OD
  • TAB FLUCONAZOLE 150mg PO/OD
  • TAB OROFER  (5) RT/OD
  • TAB LASIX 20mg RT /OD
  • Protein-x powder 2 tbsp in 1 glass of milk
  • TAB GLICIAZIDE PO/OD (1/2 tab) 
  • I/O CHARTING

DISCHARGE SUMMARY

Case:-

75 yr old male came to the casuality with c/o fever since 10 days,Altered sensorium since 6:00pm.

CHIEF COMPLAINTS:-Fever ,Altered sensorium

HISTORY OF PRESENT ILLNESS: Fever insidious onset, low grade Continous, Relieved on taking  medication.Patient was just muttering words.

HISTORY OF PAST ILLNESS:-
Patient was farmer by occupation; one day 6 yrs back patient drank Alcohol, fell from cycle, got fractured in the Right femur neck fracture got treated from local RMP.lethargic, Not interacting actively with the family members, spending more time on bed.
Bed Sores Over B/L back part of the legs

PAST HISTORY:-
No h/o similar complaints before.
No known comorbidities.

GENERAL EXAMINATION:-
No pallor,No icterus,No cyanosis,No clubbing
No lymphadenopathy,No edema.
Vitals:-
Temp- afebrile.
PR:96 BPM.
RR: 16 CPM.
Bp: 80/60 mm Hg
Spo2 : 98%
GRBS 196 MG%.

SYSTEMIC EXAMINATION:-
A. Cardiovascular system 
S1 S2 HEARD,NO MURMURS.
B. Respiratory system 
NVBS heard,BAE +,TRACHEA CENTRAL.
C. Per abdominal examination 
SOFT,NON TENDER,NON DISTENDED.
D. Central nervous system 
1. Higher Mental Function:-
Drowsy but arousable
Oriented to person, place -, time -, Registration -, attention -, Recall -
Language - spontaneous speech , - fluency, - comprehension
2. Cranial nerves -
 all cranial nerves 
                               - gag reflex
                               -  vulva position

3. Motor system - attitude -
                                       Rt.              Lt.  
          
          Tone.     UL
                         LL.       hypo
           
         Power   UL
                         LL

        Reflexes. B         +                 +
                          T
                          S
                          K
                          A
                     Plantars

4. Sensory system - Couldn't be done
                                     Deep pain +
                                     Sup pain +

5. Cerebellar system - couldn't be done
6. No signs of meningial irritation/ meningitis


PROVISINAL DIAGNOSIS:-

Fever under evaluation
Altered sensorium
Hyperglycemia


SOAP NOTES

Day -1

Subjective-

  • C/oFever
  • C/o altered sensorium 
  • hyperglycemia 

Objective:-

  • Temperature 
  • At 4am 98 F
  • At 8am 37.5 C
  • BP 80/60 mmHg
  • PR 96/mins
  • RR: 16 CPM.

Assessment :-

  • Hyperglycemia 
  • Fever with thrombocytopinea
  • Altered sensorium
  • ?UTI, DM2,hypoaluminemia?nutritional
  • Anemia

Plan of care:-
  • 1.INJ HAI IV  ( 39ml NS + HAI)@ 6ml/hr followed by infusion according to Alog-1
  • 1 hrly GRBS
  • 2.INJ PIPTAZ 4.5gm IV stat followed by INJ PIPTAZ 2.25gm I've stat
  • 3.INJ OPTINEURON 1 Amo in 100ml NS/IV/OD
  • 4.Protein powder -2tsp in 1 glass of milk /twice a day
  • 5.Rt feeds milk with protein powder - 100 my every 2 ND hrly and plain water every hrly.
  • 6.Hrly GRBS charting 
  • 7.INJ NORADRENALINE( 2amp in 50ml NS) @2ml /hr to maintain MAP >or = 6


Day-2

Subjective:-

  • C/o fever
  • C/o altered sensorium
  • Hyperglycemia resolved 

Objective:-
  • Temparature-
  • At 4am -38 C
  • At 8am -37.5 C
  • BP-80/50
  • PR-96/min
  • RR-21 cpm

Assessment :-
  • Hyperglycemia resolved
  • Right lobe pneumonia 
  • Hypoalbuminemia ?Nutritional 
  • UTI, AKI, denovo DM2,
  • NC/NC Anemia 
  • Bed sores

Plan of care:-

  • 1.IVF 10NS @75 ml/hr
  • 2.INJ PIPITAZ 2.25gm/IV/TID
  • 3.INJ OPTINEURON 1amp in 100ml NS
  • 4.TAB OROFER -XT/PO/OD
  • 5.TAB LASIX 20mg/PO/OD 
  • 6.Protein -x-powder -2tsp in 1 glass of milk /Rt feeds 2nd hrly
  •  Rt-plain water - 200ml /hrly
  • 7.INJ HALI /SC/TID 
  • 8.PR/BP/RR/SpO2 charting 2nd hourly
  • 9. GRBS charting 6th hourly
  • 10. Inj TRAMADOL 1 amp in 100 ml NS IV/OD
  • 11.TAB VITRACET 1/2 tab/RT
Day-3

Subjective:-

  • C/o fever 
  • c/o altered sensorium 
  • Hyperglycemia resolved
  • Shorts not paused 

Objective :-

  • Tempature-
  • 4-12 am -37.5 C
  • 4-8pm-98.5 F
  • 12pm-37.5 C
  • BP 110/70mmHg
  • PR 92 bpm

Assessment:-

  • Hyperglycemia resolved
  • Hypoalbuminemia ?Nutritional 
  • UTI, AKI, denovo DM2,
  • NC/NC Anemia 
  • Bed sores( +)

Plan of care:-
  • 1. IVF NS @ 75ml/hr
  • 2. Inj PIPTAZ 2.25gm/IV/TID
  • 3. Inj Optineuron 1 amp in 100ml NS IV/OD
  • 4. Tab Orofer - XT/RT/OD
  • 5. Tab Lasix 20mg/RT/OD(if SBP > 100 mg 8am---- x ---- x
  • 6. Protein-X powder 2tsp in 1 glass of milk/ RT feed 2nd hourly
  • 7. Inj HAI/SC/TID after informing Sugars to ICU Ph
  • 8. Inj Tramadol 1 amp in 100 ml NS/IV/OD
  • 9. Tab Ultracet 1/2 tablet/RT/QID1/2----1/2----1/2----1/2
  • 10. Two egg whites/day
  • 11. Bp/PR/RR/SPO2 Charting 2nd hourly
  • 12. GRBS Charting 6th hourly 8am----2pm----8pm----2am


Day-4

Subjective:-

  • c/o fever and altered sensorium
  • Hyperglycemia resolved
  • Back pain

Objective :-

  • Temperature-
  • 4-8am 37.5 C
  • 8-12am- 98.5-99 F
  • BP 100/70mmHg
  • PR 84bpm

Assessment:-

  • Hyperglycemia resolved 
  • Hypoalbuminemia ?Nutritional 
  • UTI, AKI, denovo DM2,
  • NC/NC Anemia 
  • Bed sores(+)

Plan of care:-
Rx:

  • IVF 10 NS @75 ml/hr
  • Inj.Piptaj 2.25 gm/IV/T
  • Inj.Opti Neuron 1 amp in 100ml NS/N/OD
  • TAB.Fluconazole 150 mg/PO/OD
  • TAB. OROFER RT/OD
  • TAB.Lasix 20 mg/RT/OD
  • Protein-x powder 2 tbsp in 1 glass of milk,RT feed 2 nd hourly RT plain water-200 ml hourly
  • Inj.HAI /SC/TID 
  • Inj.TRAMADOL lamp in 100 pal NS/IV/OD
  • TAB.ULTRACET 1/2 tab/RT/OD 
  • 2 egg whites/day
  • BP/PR/RR/Spo2 charting 2nd hourly
  • GRBS charting 6th hourly 8 AM-2 PM-8 PM-2 AM

Day-5

 Subjective :-
 
  •  C/o fever and altered sensorium 
 
Objective:-

  • Temperature-
  • 4-8am-37.5 C
  • BP-100/70 mmHg
  • PR-81bpm

Assessment:-
 
  • Hyperglycemia resolved 
  • Uremia
  •  Sepsis -blood cells contain kleibsiella species 
  • Hypoalbuminemia ?Nutritional 
  • UTI,  AKI, denovo DM2,
  • NC/NC Anemia 
  • Bed sores(+)
  • Alcohol dependence and
  • Tobacco dependence 


Plan of care:-

  • IVF 10NS @75ml/hrly
  • INJ PIPTAZ 2.25 gm IV/TID
  • INJ OPTINEURON 1amp in 100 ml NS/ IV /OD
  • TAB FLUCONAZOLE 150mg PO/OD
  • TAB OROFER  (5) RT/OD
  • TAB LASIX 20mg RT /OD
  • Protein-x powder 2 tbsp in 1 glass of milk
  • TAB GLICIAZIDE PO/OD (1/2 tab) 
  • I/O CHARTING




TREATMENT:-

Day-1
  • INJ HAI IV  ( 39ml NS + HAI)@ 6ml/hr followed by infusion according to Alog-1
  • 1 hrly GRBS
  • INJ PIPTAZ 4.5gm IV stat followed by INJ PIPTAZ 2.25gm I've stat
  • INJ OPTINEURON 1 Amo in 100ml NS/IV/OD
  • Protein powder -2tsp in 1 glass of milk /twice a day
  • Rt feeds milk with protein powder - 100 my every 2 ND hrly and plain water every hrly.
  • Hrly GRBS charting 
  • INJ NORADRENALINE( 2amp in 50ml NS) @2ml /hr to maintain MAP >or = 6
Day -2

  • 1.IVF 10NS @75 ml/hr
  • 2.INJ PIPITAZ 2.25gm/IV/TID
  • 3.INJ OPTINEURON 1amp in 100ml NS
  • 4.TAB OROFER -XT/PO/OD
  • 5.TAB LASIX 20mg/PO/OD 
  • 6.Protein -x-powder -2tsp in 1 glass of milk /Rt feeds 2nd hrly
  •  Rt-plain water - 200ml /hrly
  • 7.INJ HALI /SC/TID 
  • 8.PR/BP/RR/SpO2 charting 2nd hourly
  • 9. GRBS charting 6th hourly
  • 10. Inj TRAMADOL 1 amp in 100 ml NS IV/OD
  • 11.TAB VITRACET 1/2 tab/RT
Day -3

  • 1. IVF NS @ 75ml/hr
  • 2. Inj PIPTAZ 2.25gm/IV/TID
  • 3. Inj Optineuron 1 amp in 100ml NS IV/OD
  • 4. Tab Orofer - XT/RT/OD
  • 5. Tab Lasix 20mg/RT/OD(if SBP > 100 mg 8am---- x ---- x
  • 6. Protein-X powder 2tsp in 1 glass of milk/ RT feed 2nd hourly
  • 7. Inj HAI/SC/TID after informing Sugars to ICU Ph
  • 8. Inj Tramadol 1 amp in 100 ml NS/IV/OD
  • 9. Tab Ultracet 1/2 tablet/RT/QID1/2----1/2----1/2----1/2
  • 10. Two egg whites/day
  • 11. Bp/PR/RR/SPO2 Charting 2nd hourly
  • 12. GRBS Charting 6th hourly 8am----2pm----8pm----2am
Day -4 


  • IVF 10 NS @75 ml/hr
  • Inj.Piptaj 2.25 gm/IV/T
  • Inj.Opti Neuron 1 amp in 100ml NS/N/OD
  • TAB.Fluconazole 150 mg/PO/OD
  • TAB. OROFER RT/OD
  • TAB.Lasix 20 mg/RT/OD
  • Protein-x powder 2 tbsp in 1 glass of milk,RT feed 2 nd hourly RT plain water-200 ml hourly
  • Inj.HAI /SC/TID 
  • Inj.TRAMADOL lamp in 100 pal NS/IV/OD
  • TAB.ULTRACET 1/2 tab/RT/OD 
  • 2 egg whites/day
  • BP/PR/RR/Spo2 charting 2nd hourly
  • GRBS charting 6th hourly 8 AM-2 PM-8 PM-2 AM

Day -5

  • IVF 10NS @75ml/hrly
  • INJ PIPTAZ 2.25 gm IV/TID
  • INJ OPTINEURON 1amp in 100 ml NS/ IV /OD
  • TAB FLUCONAZOLE 150mg PO/OD
  • TAB OROFER  (5) RT/OD
  • TAB LASIX 20mg RT /OD
  • Protein-x powder 2 tbsp in 1 glass of milk
  • TAB GLICIAZIDE PO/OD (1/2 tab) 
  • I/O CHARTING






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