Case of 65 years old with pain in right lower limb, fever, Shortness of breath

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

Case of 65years old with Pain in right lower limb, fever and shortness of breath since 1 week.

CHIEF COMPLAINT:

1. Pain in right lower limb since 1 week.
2. Fever since 1 week
3. Shortness of breath since 1 week

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 week back, then she developed pain in right lower limb and right side of lower back- insidious in onset and gradually progressing.
No history of trauma, injury 
Fever- low grade, intermittent and associated with chills and rigor, relieved by medication
Shortness of breath- Grade II
C/o decreased urine output since 1 year
No c/o pedal edema, facial puffiness
C/o constipation- passes stools every 2-3 days
C/o decreased appetite since 1 week
No c/o pain abdomen, burning micturition, chest pain, palpitations

PAST HISTORY:

Known case of hypertension since 10 years, on regular medication TAB. AMLO -AT 5/50 OD

Not a known case of DM, TB, Epilepsy, CVA, CAD, Thyroid disorders, Bronchial asthma.

TREATMENT HISTORY:


On medication for HYPERTENSION TAB. AMLO -AT 5/50 OD since 10 years.

PERSONAL HISTORY:


1.Diet-mixed

2.Appetite: decreased since 1 week

3.Bladder movements - decreased since 1 year

4.Bowel: constipation, passes stools for every 2-3 days

5. Sleep -adequate

6.Addictions-nil

DAILY ROUTINE:
At 7am-wakes up
7:30am has tea and starts doing her daily chores, meanwhile she eats her breakfast at around 11am
Watches tv and takes rest till 4pm 
Has tea at 5pm
Starts dinner preparation at 6pm
At 8 pm she eats dinner
9pm sleep




FAMILY HISTORY: 

Insignificant 

GENERAL EXAMINATION:

The patient was examined in a well-lit room after informed consent was taken.

She is conscious, coherent, cooperative, well oriented to time, place and person, well nourished and moderately built.

No pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.






VITALS:

  1. Temp: 99.1 F
  2. BP: 120/70mm Hg
  3. PR: 78bpm
  4. RR: 18cpm
  5. Spo2: 96% on RA
  6. GRBS : 87mg/dl

SYSTEMIC EXAMINATION:

RS: BAE present, Normal vesicular breath sounds heard
CVS: S1, S2 heard
CNS: No focal neurological deficit
PER ABDOMEN: soft, non tender

INVESTIGATIONS:


29/7/2023

CBP:

Hb:  12.7 gm/dl

TLC:   14100 cells/ cumm

RBC:   4.78 million/cumm

PLT:   4.50 lakh/cumm

PCV: 39.6  vol%

Neutrophils:71 %

Lymphocytes:21 %

Eosinophils: 2%

Monocytes: 6%

MCV: 82.8 fl

MCH:26.6 pg

Peripheral Smear: Normocytic normochromic blood picture with leucocytosis

RFT:

Blood urea:  37 mg/dl

Serum creatinine: 0.8 mg/dl

Serum electrolytes: 

Na+:   142 mEq/l

K+:  4.5 mEq/l

Chloride :  99 mEq/l


LFT:

Total bilurubin:0.68mg/dl

Direct bilurubin :0.20 mg/dl

AST:33 IU/L

ALT:43 IU/L

Alk phosphatase:249 IU/L

Total Protien:6.4 gm/dl

Albumin:3.0 gm/dl

A/G ratio: 0.89

CUE:

Albumin:nil

Sugars:nil

Pus cells:2-3/HPF

Epithelial cells:2-3/HPF


RBS: 76mg/dl


Serology: NEGATIVE


USG ABDOMEN AND PELVIS: Impression

1. Right grade I RPD changes.

2. Raised echogenicity of left kidney 

USG CHEST: Impression

B/L mild pleural effusion 

2D ECHO:

Trivial TR+, No MR/AR

No RWMA, No AS/MS, Sclerotic AV

Good IV systolic function

Diastolic dysfunction +, No PAH/PE.

Chest X-ray:


Xray LS spine:decreased L5 disc space.



Xray B/L knees: Grade IV osteoarthritis knee.



MRI LS spine and whole spince screening : Impression-
1. L3-L4 infective spondylodiscitis
2. L3-L4 disc protrusion causing sever canal stenosis
3. Thin rim of prevertebral collection at L3-L4 level
4. 30x14mm and 20x11mm collection in right psoas muscle.
5. Small bilobed epidural collections behind L3-L4 vertebral bodies




PROVISIONAL DIAGNOSIS:

Pyrexia under evaluation with mild B/L pleural effusion.

TREATMENT:

1. INJ. NEOMOL 1gm IV/SOS ( if temperature >101F)
2. INJ. OPTINEURON 1amp in 100 ml NS IV/OD
3. INJ. MONOCEF 1gm IV/BD 
4. TAB. PCM 650mg PO/BD
5. TAB. AMLONG -AT 5/50 PO/OD
6. INJ. TRAMADOL 1amp in 100ml NS IV/BD

Orthopaedic management of the case:

1. Inj. TRAMADOL 1amp in 100ml NS IV/BD
2. TAB GABAPENTIN 100mg H/S x 15days
3. TAB. EVION LC BD x 15days
4. TAB. MYORIL 4mg BD x 3days

Advised for L3-L4 vertebral body biopsy and L2- L5 Posterior screw fixation.



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