32Y Male with FEVER and DYSPHAGIA since 1 WEEK

 Introduction: This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs. 

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

A 32-year-old man, pharmacist by occupation presented to the outpatient department with the,

CHIEF COMPLAINTS:

1. Fever since 1 week.

2. Difficulty in swallowing since 1 week.

HISTORY OF PRESENTING ILLNESS:

1.  Patient was apparently asymptomatic 6 years back when he met with an accident (RTA - bike vs lorry) and sustained following injuries:

                           - Left femur fracture: Intramedullary Nailing done

                                                         - Tibia fracture: Plating done

                                           

     2. Patient went for follow up after 4 months because of constant pain and was informed about nonunion of femur shaft fracture and tibial fracture.                              

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Underwent revision surgery under another doctor for Intramedullary nailing without any bone graft.

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1-2 days after the revision surgery, patient noticed relative motion of Femur nail and underwent revision surgery for screw tightening. 

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The patient gradually started walking with support but complained of pus discharge from the operated site over femur, intermittently since 6 years. 

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     In 2018, patient noticed discharging sinuses - 2 in proximal near left gluteal region and 2 in distal femur and was treated with Inj Peptaz, intravenous amikacin and intraosseous gentamicin for 20 days.

  

     3.  3 months back Nails and plates were removed as the patient’s doctor had advised in view of delayed bone healing. 

     4. 1 week back developed fever, high grade, associated with chills and rigors

                 -   No h/o fever spikes since 2 days.

     5.  C/O difficulty in swallowing since 1 week, both to liquids and solids, associated with burning sensation in throat.

DAILY ROUTINE: 

Prior to the accident patient worked in a medical shop near his house.

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He used to wake up at 6AM, have tea/coffee, eat breakfast and leave for work.

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He left for work around 9Am by walk and used to return home by evening 6PM. 

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 Post the accident, patient was initially bed ridden for 1 year, and then gradually started walking with support. 

On 17th June, prior to coming to our hospital, the patient was taken to a local hospital, where following investigations were done:

• Hemoglobin: 10.6 g/dl (Normal 13-16gms)
• Total RBC Count: 4.60 million/cumm (Normal 4.5-6.5 mill)
• Platelet Count: 5.98 Lakhs/cumm (Normal 1.5-4lakhs)
• Total WBC Count: 22,500/cumm (Normal 4,000-11,000/cumm)
• Total Bilirubin: 0.7mg/dl (TB Normal 0.1-2mg)
• Malaria Test: Negative
• Widal Test: S Typhi "O" Positive (1:160) , S Typhi "H" Positive (1:80) 

On 21st June, prior to coming to our hospital, the patient was taken to a local hospital, where following investigations were done:

• Hemoglobin: 8.1 g/dl (Normal 13-16gms)
• Total RBC Count: 2.7 million/cumm (Normal 4.5-6.5 mill)
• Platelet Count: 2.4 Lakhs/cumm (Normal 1.5-4lakhs)
• Total WBC Count: 13,300/cumm (Normal 4,000-11,000/cumm)
• RBS: 158mg/dl (Normal 80-170)
• Blood Urea: 55mg/dl (Normal 14-45)
• Serum Creatinine: 2.89mg/dl (Normal 0.6-1.2)

PAST HISTORY:

• Patient is a known case of Diabetes Mellitus type 2, since 6 months, on T Glimiperide 1mg + T Metformin 500mg.
• Patient is not a known case of Hypertension, Thyroid disorders, Seizures, Tuberculosis, Asthma, stroke or any cardiac disorder.
• History of previous surgery - Nailing for Femur fracture and Plating for Tibia fracture, 6 years ago.

PERSONAL HISTORY:

• His appetite has decreased since past 1 week, he consumes a mixed diet, sleep is disturbed 
• Bowel movements are normal but Decreased urine output since the last couple of days whenever fever spiked.
• No history of smoking or alcohol.
• No known food or drug allergies.

FAMILY HISTORY:

• No similar complaints in the family members.

GENERAL PHYSICAL EXAMINATION:

Examination has been done in a well-lit room in supine and sitting posture after taking informed consent and after reassuring the patient.

• Patient was conscious, coherent, co-operative and well oriented to time, place and person.
• Moderately built and nourished.
• Pallor present.
• No signs of Icterus, Cyanosis, Clubbing, Pedal edema, Generalized Lymphadenopathy.
• JVP normal.   

                                                  

        

   

SYSTEMIC EXAMINATION:

Central Nervous System:  No abnormality detected.

Per Abdomen: Soft and nontender, no organomegaly. 

Cardiovascular System: S1, S2 heard, no murmurs 

Respiratory System: BAE+, NVBS +

Vitals:

22/06/2023

Temperature - 99.6F (two fever spikes in the night)

Respiratory Rate - 23 cpm

Pulse Rate - 110 bpm

Blood Pressure - 100/70 mm Hg

SpO2 - 99 at room air

23/06/2023

Temperature - 99.4F

Respiratory Rate - 22 cpm

Pulse Rate - 115 bpm

Blood Pressure - 110/70 mm Hg

 

24/06/2023

Temperature - 100.4F

Respiratory Rate - 24 cpm

Pulse Rate - 108 bpm

Blood Pressure - 100/60 mm Hg

Input/Output - 2400/900ml

25/06/2023

Temperature - 100.2F

Respiratory Rate - 22 cpm

Pulse Rate - 120 bpm

Blood Pressure - 100/60 mm Hg

GRBS @ 8Am - 300mg/dl 10 units HAI and 6NPH given

Input/Output - 3700/1200ml

INVESTIGATIONS:

22nd JUNE

1.  BLOOD UREA: 55MG/DL (Normal 12-42)
2. SERUM CREATININE: 1.2MG/DL (Normal 0.9-1.3)
3. C REACTIVE PROTEIN: POSITIVE 1.2MG/DL (Normal 0.3-1)
4. Serology Rapid HBsAg/HIV1/2/Anti HCV - Negative
5. RBS: 115mg/dl (Normal 80-170)
6. BGT: O Positive
7. LFT's:

      10. Serum Electrolytes:

         

      11. Complete Blood Picture:

NC/NC Anemia with Leukocytosis and Thrombocytosis.

23rd JUNE

1. Spot Urine Sodium: 123mmol/L

2. Spot Urine Potassium: 6.6

3. Urinary Chloride: 154mmol/L

4. HBa1C: 6.7%

5. FBS: 227mg/dl 

6. Blood Lactate: 6.9mg/dl 

7. LDH: 190 IU/L

8. PT/INR: 18sec/1.30

9. APTT: 35 sec

24th JUNE

1. Blood Urea: 14mg/dl (Normal 12-42)
2. Serum Creatinine: 0.9 mg/dl(Normal 0.6-1.2)
3. PLBS: 196mg/dl

25th JUNE

1. Serum Creatinine: 0.9 mg/dl 

2. Blood Urea: 10 mg/dl

26th JUNE

 1. Serum Creatinine: 0.7 mg/dl 

2. Blood Urea: 10 mg/dl

ENT OPINION:

 ( oral candidiasis) 

ORTHOPEDIC  OPINION: 

27th June 

 1. Serum Creatinine: 0.7 mg/dl 

2. Blood Urea: 13 mg/dl

28th JUNE

1 unit PRBC transfusion done

29th JUNE

Underwent Wound Debridement under CSE: 

30th JUNE

1. Serum Creatinine: 0.6 mg/dl 

2. Blood Urea: 14 mg/dl

1 unit PRBC transfusion done

X-ray Left thigh: 

X-ray Left thigh: 

1st JULY

2nd JULY

3rd JULY

5th JULY

6th JULY

 Grade 1 Bedsore 

7th JULY

Underwent incision and drainage

Tissue Sample sent for culture: 

8th JULY 

1 unit PRBC transfusion done

Dressing: 

9th JULY 

1. Serum Creatinine: 0.4 mg/dl 

2. Blood Urea: 19 mg/dl

10th JULY

11th JULY

12th JULY

1. Serum Creatinine: 0.5 mg/dl 

13th JULY

Grade 2 Bedsore

1 unit PRBC transfusion done

14th JULY

15th JULY

16th JULY

17th JULY

PROVISIONAL DIAGNOSIS:

Sepsis with ( AKI resolved) (ALI resolved)

- Chronic osteomyelitis of Left Femur 

- with ? Oral candidiasis (resolved) 

- with Type 2 DM since 6 months 

- with Anemia (? Secondary to chronic inflammation)

- with Thrombophlebitis of Right lower limb (resolved) 

- with Grade 2 bedsore 

TREATMENT:

1. IVF NS @150ml/hr

2. Inj NEOMOL 1g/IV/SOS ( if temp > 101F)

3. Inj LINEZOLID 600mg/IV/BD

4. Inj TRAMADOL 1amp in 100ml NS IV/BD

5. Inj HAI/SC TID and Inj NPH S/C BD according to GRBS

6. Inj NORADRENALINE @ 5ml/hr accordingly to maintain MAP > 65mmhg 

7. Inj KCL 2 amp in 1 unit NS over 5 hours 

8. Inj Clexane 45 units S/C OD

9. Soft diet, egg whites