Case discussion on 65 year male patient with fever and cough

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Long case 

1701006128

Case discussion of 65 year male with Fever and Cough 

A 65 year old male patient, a former daily wage labourer and resident of Cherlapally came with the chief complaints of: 

Cough with sputum since 1 month

Shortness of breath since 5 days 

Abdominal pain since 5 days

Fever since 5 days 

Timeline of events and History of Presenting illness 

Patient was a daily wage labourer who did not have any significant morbidity, ever requiring hospitalization 

2 years back, he stopped going to work due to tiredness

1 year back, he had similar complaints of fever and cough with sputum. On visiting a local Registered Medical Practitioner (RMP) he was diagnosed with having Pulmonary tuberculosis and started on Anti tubercular therapy.

Patient took treatment for 2 months and then discontinued as he felt that he recovered.

1 month back, the patient developed cough and went to a local RMP who started him on some medication that the patient says is the same as before, therefore, Anti TB medication that he is continuing to take.

5 days back, the patient's cough was aggrevated in a way that he would get bouts of wet cough along with shortness of breath,abdominal pain and fever 

He went to a local hospital. On investigation was found to be Diabetic (de novo). Was refered to our hospital for treatment.

Cough has been present for a duration of 1 month. It is wet cough with thick, dark red sputum of mucoid consistency. The sputum in amount  can fill half cup and was sometimes blood stained. No aggrevating or relieving factors 

Shortness of breath has been present for a period of 5 days.Gradually progressive He is not able to walk because of it, putting that at MMRC grade 4. It was aggrevated on sitting up . Relived on lying in right lateral decubitus position

He also has been complaining of abdominal pain since 5 days. The pain was sudden in onset and progressive. It is diffuse, persistent  type of pain with no referal, radiation or migration,aggrevating or relieving factors. 

Patient has been febrile for the past 5 days. Incidious in onset and progressive, continuous with no diurnal variation. It was not associated with chills and rigours, vomiting, diarrhoea or headache. 

Patient also has burning micturition since 5 days.  He did not complain of any decreased urine output nor any increased frequency of micturition, did not complain of poor stream, nocturia or urgency. No pedal edema. Pain was not radiating nor any referral. No aggrevating or relieving factors.

Patient also has weight loss. He weighed 60kg a year back but now weighs 45kg. 

Patient did not give any complaints of vomiting, diarrhoea, constipation, abdominal distension, headache.

Past history: 

Similar complaints 1 year back as mentioned.

He is a known case of Tuberculosis. De novo Diabetes Mellitus.

Not a known case of hypertension, asthma, epilepsy, coronary artery disease or any bleeding disorders

No surgeries, blood transfusions in the past 

Drug history: Anti tubercular drugs 

Personal history: 

He takes mixed diet 

Appetite is reduced due to abdominal pain 

Bowel and bladder are regular 

Sleep is inadequate 

No allergies 

Chronic smoker: 3 packs of beedi per day for 50 years   (Smoking index= 3×9×50= 1350) 

Chronic intake of alcohol: 90 ml per day for 50 years 

Family history: No similar complaints in the family. No history of tuberculosis in the family 

General Examination: 

Patient is examined in supine position in a well lit room, after taking informed consent. 

He is breathless and clearly using accessory muscles for respiration.

Patient is conscious, coherent and cooperative. Poorly built and poorly nourished (emaciated) 

On examination there were no signs of pallor, icterus, cyanosis, clubbing, koilonychia, generalized lymphadenopathy, generalized edema or pedal edema.

His vitals were: 

Temperature: 102° F 

Pulse rate: 112 bpm

Respiration: 18 cpm 

Blood pressure: 130/90 mmHg 

GRBS:  173 mg%

Systemic Examination of Lower Respiratory system:

Patient is observed in supine position. 

Inspection 

Abdomino thoracic type of breathing 

Trachea is central 

Chest looks to be barrel shaped. It is symmetrical.

Movements are slightly decreased on right side 

No scars, sinuses or visible pulsations 

No nasal flaring 

Suprasternal and supraclavicular notching is present 

Apical impulse not seen

Palpation 

No local rise of temperature 

No tenderness 

Inspectory findings are confirmed: Trachea is central, movements decreased on right side. 

Anteroposterior diameter of chest >Transverse diameter of chest

No crowding of ribs, rachitic/scorbutic rosary 

Apex beat felt in 5th intercostal space

Tactile vocal fremitus: 

Supraclavicular: Decreased on right, felt on left      

Infraclavicular: Decreased on right, felt on left                    

 Inframammary:  Decreased on right, felt on left           

Axillary: Decreased on right, felt on left                              

Infraaxillary: Decreased on right, felt on left                  

Suprascapular      

Interscapular: Not examined                                  

Intrascapular                

Percussion 

Supraclavicular: Stony dull on right, Resonant on left 

 Infraclavicular: Stony dull on right, Resonant on left        

 Inframammary: Stony dull on right, Resonant on left   

Axillary: Stony dull on right, Resonant on left                 

Infraaxillary: Stony dull on right, Resonant on left        

Suprascapular      

Interscapular: Not percussed 

Intrascapular        

 

Auscultation 

Breath sounds were decreased on right side in all areas.

Vocal resonance was decreased on right side in all areas.

Adventitious sounds: Not heard

Examination of other systems: 

Cardiovascular system:  S1 S2  heard, no murmers

Central Nervous system: Intact 

Abdominal examination: Guarding, rigidity and tenderness present 

Provisional diagnosis: 

Right sided Pleural effusion secondary to community acquired Pneumonia (Parapneumonic effusion) 

 De novo Diabetes Mellitus 

Differential diagnosis: 

Reactivation of tuberculosis: Tubercular Pleural effusion

Investigations: 3/06/2022

Hemoglobin: 10.7 gm/dL (decreased)

Total Leucocyte Count: 34,500/ microlt (increased)

Absolute Leucocyte Count:

Neutrophils: 92 

Lymphocytes: 4 

Eosinophils: 0 

Monocytes: 4 

Basophils: 0

Packed cell volume: 29.7 (decreased)

Mean Corpuscular volume: 81.1

Mean Corpuscular hemoglobin: 29.2

Mean Corpuscular  hemoglobin concentration: 36

RBC: 3.66 million/ microlt

Platelets: 2.5 lakh/ microlt 

Blood smear: Normocytes Normochromic 

Random blood sugar: 210 mg/dL (elevated)

Blood urea: 105 mg/dL (elevated)

Serum creatinine: 3.9 mg/dL (elevated)

Serum electrolytes: 

Sodium: 135 mEq/L 

Potassium: 4.1 mEq/L 

Chloride: 98 mEq/L 

Complete urine examination: 

Pale yellow, clear urine

Albumin + 

Sugar ++ 

Urinary electrolytes: Sodium- 238; K- 15.8; Cl- 302 mEq/day 

Spot urine: Protein 17 mg/dL; Creatinine: 28 mg/dL; Ratio: 0.60 

Liver function tests: 

Total bilirubin: 1.09 mg/dL

Direct bilirubin: 0.19 mg/dL 

SGOT: 14 IU/L

SGPT: 10 IU/L

Alkaline Phosphatase: 722 IU/L (elevated)

Total proteins: 5.3 gm/dL 

Albumin: 2.97 gm/dL (decreased)

Albumin: Globulin ratio: 1.27

Pleural Tap was done 

Wide bore needle used to do Pleural tap. (Image obtained from internet)

Pleural fluid had:  

Sugar: 178 mg/dL 

Protein: 3.8 gm/dL 

LDH: 561  

Serology: Negative 

Ultrasound of abdomen report showed: 

Bilateral Grade 2 Renal Parenchymal disease 

     Simple Renal cortical Cysts 

                              Right side 3mm Renal calculi in lower pole 

Electrocardiogram: 

Arterial Blood gas (ABG) report on 3/06/2022 at 6:17 pm: 

pH  - 7.13

pCO2 - 16.8

pO2 - 106

HCO3 - 5.4

St.HCO3 - 8.9

BEB - (-)23.3

BEecf - (-)22.3

TCO2 - 11.3

O2 saturation - 95.5

Investigations: 4/06/2022 

Blood urea: 70 mg/dL (elevated)

Serum creatinine: 5 mg/dL (elevated)

Chest x ray:

Obliteration of right costochondral junction

ABG on 4/06/2022 at 7:25 pm:

pH - 7.22

pCO2 - 16.9

pO2 - 70.3

HCO3 - 6.8

St.HCO3 - 10.2

BEB - -19.5

BEecf - -19.7

TCO2 - 14.4

O2 saturation - 92.3

Investigations: 5/06/2022

Blood urea: 58 mg/dL (elevated)

Serum creatinine: 7.2 mg/dL (elevated)

ABG on  5/06/2022 at 1:56 pm 

pH - 7.17

pCO2 - 17.0

pO2 - 101

HCO3 - 5.9

St.HCO3 - 9.1

BEB - -21.3

BEecf - -21.2

TCO2 - 13.0

O2 saturation - 95.3

Treatment given: 

1) IV Fluids NS @ 50 mL/hr 

2) Inj Augmentin 1.2 gm IV/TID 

3) Inj Neomol 1 gm IV SOS 

4) Inj Optineuron 1 Amp in 100 mL NS IV OD 

5) Inj Lasix 40 mg IV BD 

6) Inj PAN 40 mg IV OD 

7) T. DOLO 650 mg PO QID 

8) T. AZEE  500 mg PO OD

9) NEB with Duolin 8th hourly and Budecort 12th hourly 

10) Inj Zofer 4mg IV SOS 

Follow up: 

On 5/6/2022

 Patient developed Left side hemiplegia which worsened GCS 

MRI brain revealed Acute ischemic stroke in the right middle cerebral artery territory (infarct) 

Treatment added: 

Tab Ecosprin 150mg OD 

Tab Clopitab 75 mg OD 

Tab Atocor 20 mg OD 

On 6/6/2022 at 4:25 AM: 

Patient became unresponsive with no cardiac activity 

6 cycles of CPR with intubation and ROSC obtained. Patient was mechanically ventilated.

At 6:05 AM: 

Patient again went into cardiac asystole 

6 cycles of CPR failed to revive the patient 

Declared dead at 6:35 am on 6/6/22 

Cause of death:  

Sepsis with Multi organ damage 

Septic shock 

Refractory metabolic acidosis