A case of a 61 yr old man with community acquired pneumonia and Bicytopenia on evaluation.

This is an E log book to discuss our patients de-identified health data shared after guardians informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.

This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most welcome.

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis "to develop my competency and comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.

A 61 year old male patient came to the hospital with chief complaints of :

CHIEF COMPLAINTS

Dry cough since 10 days

Dragging pain towards the finger tips since 10 days

Lower back pain since 10 days

Shortness of breath

Chest pain near heart since 10 days

 HISTORY OF PRESENTING ILLNESS

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEARS AGO WHEN 

He noticed involuntary movements of upper right limb at rest and decreased on movement

2 years ago he increased the intake of alcohol, then 1 year back he noticed slowing of movements and decrease in his pitch of voice.

He has used medication but stopped after 5 months due to lack of improvement of symptoms,

Since 20 days back he has trouble recollecting and takes at least 30-40 minutes to perform any activity.

10 days back he experienced dry cough, 

Lower back pain on both sides draging type radiating downwards

Pain in upper right arm radiating towards the finger tips dragging in nature 

Both of which were relieved on medication and rest

Chest pain with burning sensation since 10 days 

Shortness of breath Grade 2 -3

Not relieved on rest 

Not associated with vomiting or headaches.

PAST HISTORY

10 days back had an episode of fever which subsided on medication

Not a known case of

Diabetes 

Hypertension

Tb 

Asthama

Epilepsy

Cvd

FAMILY HISTORY

Not significant

PERSONAL HISTORY

Diet - mixed

Appetite - Decreased 

Bowel and bladder - adequate

Allergies -no

Addiction

18 ciggarettes per day and daily intake of alcohol.

GENERAL EXAMINATION

Thin built and malnourished 

Vitals

Temperature : Afebrile 

Pulse: 81

BP:110/80 mm/ hg

RR :18 

SPO2 : 97%

Pallor : present 

Icterus present

Clubbing absent

Cyanosis absent

Lymphadenopathy absent

Pedal edema absent

JVP RAISED 

SYSTEMIC EXAMINATION

CVS

Apex beat 6 th intercoastal space

No thrills

S1 S2 heard

No murmurs

RESPIRATORY SYSTEM

No dyspnoea wheeze

Central trachea 

Bilateral air entry +

Bilateral basal crepts +

ABDOMEN

Soft

Non tender

CNS

Higher functions

Patient is conscious, coherent,and co operative

Patient is oriented to place not to time and person

Delay in response but able to recall

Cranial nerve intact

Examination of motor system 

Tone increased on right upper limb

Not able to approximate both upper limbs

Power of muscle normal

Coordination of movement 

Tremors : resting

                 pill rolling movement

Reflex

Sensory system

Normal

INVESTIGATIONS

Day 1 

 

 

 

 

Day 2

Day 3

Day 4

Day 5

 

 

 

Day 6

 

 

Day 7

 

 

 

 

 

Day 8

Day 9

Peripheral blood smear

Peripheral blood smear - 2

PROVISIONAL DIAGNOSIS

BICYTOPENIA  
COMMUNITY ACQUIRED PNEUMONIA WITH (BILATERAL LOWER LOBE CONSOLIDATION)
WITH 
MODERATE HEPATOSPLEENOMEGALY
WITH
HYPONATREMIA (RECOVERED )2 TO SIADH? 
ALTERED MENTATION

Day 1

S :- 

Patient is having resting tremors

Delayed speech

Altered sensorium

O:-

Pt is conscious, coherent cooperative

Bp:-140/70

Pr:-92 bpm

Cvs:-s1s2+

R/s:-BLAE +

P/A:- soft , non tender spleenomegaly

CNS:- NAD

A:-

BICYTOPENIA UNDER EVALUATION

WITH

 COMMUNITY ACQUIRED PNEUMONIA WITH PARKINSON'S WITH 

MODERATE SPLEENOMEGALY

P:-

Inj AUGMENTIN 1.2g/IV/BD

TAB AZITHROMICIN 500 mg/PO/OD

INJ OPTINEURON 1 amp 100 ml /NS

Vital monitoring

Temperature monitoring

Day 2

S :- 

Patient is having resting tremors

Delayed speech

O:-

Pt is conscious, coherent cooperative

Bp:-120/70

Pr:-93 bpm

Cvs:-s1s2+

R/s:-BLAE +

P/A:- soft , non tender spleenomegaly

CNS:- NAD

A

BICYTOPENIA UNDER EVALUATION

WITH

 COMMUNITY ACQUIRED PNEUMONIA WITH PARKINSON'S(?)WITH 

MODERATE SPLEENOMEGALY

P:-

Inj AUGMENTIN 1.2g/IV/BD

TAB AZITHROMICIN 500 mg/PO/OD

INJ M6RVIG6M1000 micrograms//IV/OD IN 50 ML NS

INJ OPTINEURON 1 amp 200 ml /NS

Vital monitoring

Temperature monitoring

Day 3

S :- 

Patient is having resting tremors

Delayed speech

O:-

Pt is conscious, coherent cooperative

Bp:-110/80

Pr:-86 bpm

Cvs:-s1s2+

R/s:-BLAE +

P/A:- soft , non tender spleenomegaly

CNS:- NAD

A:-BICYTOPENIA UNDER EVALUATION

WITH

 COMMUNITY ACQUIRED PNEUMONIA WITH PARKINSON'S(?)WITH 

MODERATE SPLEENOMEGALY

P:-

Inj AUGMENTIN 1.2g/IV/BD

TAB AZITHROMICIN 500 mg/PO/OD

INJ M6RVIG6M1000 micrograms//IV/OD IN 50 ML NS

TAB PANTOPRAZOLE 40 MG/PO/OD

Vital monitoring

Temperature monitoring

Day 4

S :- 

Patient is having resting tremors

Delayed speech

O:-

Pt is conscious, coherent cooperative

Bp:-110/80

Pr:-86 bpm

Cvs:-s1s2+

R/s:-BLAE +

P/A:- soft , non tender spleenomegaly

CNS:- NAD

A:-BICYTOPENIA UNDER EVALUATION

WITH

 COMMUNITY ACQUIRED PNEUMONIA WITH PARKINSON'S(?)WITH 

MODERATE SPLEENOMEGALY

P:-

Inj AUGMENTIN 1.2g/IV/BD

TAB AZITHROMICIN 500 mg/PO/OD

INJ M6RVIG6M1000 micrograms//IV/OD IN 50 ML NS

TAB PANTOPRAZOLE 40 MG/PO/OD

Vital monitoring

Temperature monitoring

Day 5

S :- 

Patient is having resting tremors

Fever spikes

Shortness of breath

Pain at bone marrow biopsy site

Delayed speech

O:-

Pt is conscious, coherent cooperative

Bp:-110/70

Pr:-92 bpm

Cvs:-s1s2+

R/s:-BLAE +

P/A:- soft , non tender spleenomegaly

CNS:- NAD

A:-BICYTOPENIA UNDER EVALUATION(2 to malignancy infection) 

WITH

 COMMUNITY ACQUIRED PNEUMONIA WITH ESSENTIAL TREMORS WITH 

MODERATE SPLEENOMEGALY

P:- 

TAB AZITHROMICIN 500 mg /PO/OD

TAB ULTRACET1/2tab /QID

TAB PANTOPRAZOLE 40 MG/PO/OD

INJ PIPTAS 4.5gm /IV/TID

TAB ZINCOVIT OD/PO

Vital monitoring

Temperature monitoring

Day 6

S :- 

Patient is having resting tremors

Pain at bone marrow biopsy site

Delayed speech

O:-

Pt is conscious, coherent cooperative

Bp:-120/80

Pr:-98 bpm

Cvs:-s1s2+

R/s:-BLAE +

P/A:- soft , non tender spleenomegaly

CNS:- NAD

A:-BICYTOPENIA UNDER EVALUATION(2 to malignancy infection) 

WITH

 COMMUNITY ACQUIRED PNEUMONIA WITH ESSENTIAL TREMORS WITH 

MODERATE HEPATOSPLEENOMEGALY

P:- 

TAB DOLO 650 mg /PO/OD

TAB ULTRACET1/2tab /QID

TAB PANTOPRAZOLE 40 MG/PO/OD

INJ PIPTAS 4.5gm /IV/TID

TAB ZINCOVIT OD/PO

Vital monitoring

Day 7

S :- 

Patient is having resting tremors

Altered behavior GCS E4V4M4

Involuntary Micturation

Fever spikes

Pain at bone marrow biopsy site

Delayed speech

O:-

Pt is conscious

Bp:-110/60

Pr:-130 bpm

Cvs:-s1s2+

R/s:-BLAE +

P/A:- soft , non tender spleenomegaly

CNS:- NAD

A:-BICYTOPENIA UNDER EVALUATION(2 to malignancy infection) 

WITH

 COMMUNITY ACQUIRED PNEUMONIA WITH ESSENTIAL TREMORS WITH 

MODERATE HEPATOSPLEENOMEGALY

P:- 

Riley's tube

Foleys catheter

IVF 3% Nacl at 10ml/hr

INJ MEROPENUM 1g IV STAT

INJ MEROPENUM 1g IV/BD

Temperature charting

Vital monitoring

Ryles feed

Day 8

S :- 

Patient is having resting tremors

Altered behavior

Fever spikes

Delayed speech

O:-

Pt is conscious

Bp:-130/70

Pr:-110 bpm

Cvs:-s1s2+

R/s:-BLAE +

P/A:- soft , non tender spleenomegaly

CNS:- NAD

Kerning sign positive

A:-BICYTOPENIA UNDER EVALUATION(2 to malignancy? infection? ) 

WITH

 COMMUNITY ACQUIRED PNEUMONIA WITH ESSENTIAL TREMORS WITH 

MODERATE SPLEENOMEGALY

ACUTE SYMPTOMATIC HYPONATREMIA 2 TO SIADH? 

ALTERED SENSORIUM 2 TO HYPONATREMIA? MENINGITIS? 

P:- 

Riley's tube

Foleys catheter

IVF 3% Nacl at 10ml/hr

INJ MEROPENUM 500 mg IV/BD

INJ OPTINEURON 1 AMP IN 100 ml NS/IV/OD

INJ NEOMOL 1 gm IV/SOS

TAB DOLO

Temperature charting

Vital monitoring

Ryles feed

Day 9

S :- 

Patient is having resting tremors

Altered behavior

Fever spikes

Delayed speech

O:-

Pt is conscious

Bp:-110/60

Pr:-120 bpm

Cvs:-s1s2+

R/s:-BLAE +

P/A:- soft , non tender spleenomegaly

CNS:- NAD

Kerning sign positive

A:-BICYTOPENIA UNDER EVALUATION(2 to malignancy? infection? ) 

WITH

 COMMUNITY ACQUIRED PNEUMONIA WITH ESSENTIAL TREMORS WITH 

MODERATE SPLEENOMEGALY

ACUTE SYMPTOMATIC HYPONATREMIA 2 TO SIADH? 

ALTERED SENSORIUM 2 TO HYPONATREMIA? MENINGITIS? 

P:- 

Riley's tube

Foleys catheter

IVF 3% Nacl at 10ml/hr

INJ MEROPENUM 500 mg IV/BD

INJ OPTINEURON 1 AMP IN 100 ml NS/IV/OD

INJ NEOMOL 1 gm IV/SOS

TAB DOLO

Temperature charting

Vital monitoring

Ryles feed