56M PUO 1 MONTH DM2 10 YEARS

06-12-2024

This is an online E Log Book to discuss our patirnt's de-identified health data shared after taking his signed informed consent.  Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

In this case the 56 year old male was a government bus driver and took up auto driving since last two months!  He is a known case of diabetes mellitus 2 since 10 yrs.

The patient came to the hospital with insidious onset of intermittent backache and pain abdomen with fever spikes ever since he retired as a government bus driver and took up auto driving since last two months! since one month he stopped auto driving also due to persistent fever albiet internittent.

PPM 1 - Currently on the above tabs twice a day for his diabetes.

PPM 1 - Today's notes.

PPM 1 - @PPM3 please share his chest X-ray, ultrasound, hemogram and LFT reports.

PPM 3 - 

PPM 1 - Thanks. Ultrasound?

PPM 1 - Currently LFT, blood and urine c/s is pending.

Have we added Tablet Nitrofurantoin? @PPM3?

PPM 3 - Okay sir.

07-12-2024

PPM 1 - Now if this fever spike is absent for today but reappears on Sunday we may have to treat him as clinical malaria based on fever pattern driven diagnosis.

PPM 3 - Ok sir.

PPM 1 - Please update his 7 point sugar profile since yesterday.

PPM 3 -

 10am - 116

1pm - 139

4pm - 265

8pm - 327

10pm- 263

2am - 200

8am - 246

PPM 2 - Malaria for 1 month?

PPM 1 - Currently only on empirical nitrofurantoin?

PPM 2 - Would you think that eosinophilia is relevant at all?

Any parasites being suspected? Perhaps he will need a very thorough social history and sequence of events? Travel? Exposures?Z virus?

Weight loss? Bowel symptoms? Appetite?

I wouldn't put MSM far away. Did have 2 such patients at SVS - both car drivers - who were MSM and turned out to have epidemiology specific to MSM

PPM 1 - We may need to increase his glimiperide by 0.5 mg

@PPM3 please share any details of his sexual history of exposure. Also have we gotten all the viral serology tests done?

PPM 3 - Ok sir.

PPM 3 - He is C/O. Chills @6pm today sir , but Temp is 98.1 , yesterday also , had similar complaint at same time with fever spike sir

PPM 1 - Thanks. Perhaps we shall have the answer to his fever by Monday but do keep charting 4 hourly

PPM 3 - H/O. weight loss of up to more than 5kg , loss of appetite since 1 month , constipation for 3 days followed by loose stools for 1 day since 1 month, lower abdomen pain since then.

No H/O. Exposure

PPM 2 - Z, Addison, Proctocolitis (from MSM which I still think is possible as we had to really dig last time due to stigma), TB, Malignancy, IBD etc.

History of incontinence? Recurrent UTI? Haematuria? Pyuria?

PPM 3 - H/o. Burning micturition since 1 month, no H/o. incontinence 

1 month back he had hematuria

PPM 2 - Genitourinary + Lower GI + Systemic Inflammation =?MSM @PPM3 @PPM1 sir?

PPM 3 - ?? Abdominal TB / ? Malignancy sir

PPM 2 - I agree but does it explain the Genitourinary symptoms?

Does he return to home always? Or does he sometimes go on long drives and comes back after 2 3 days. Does he sometimes stay in a hostel?

A direct examination of his perianal area would be extremely helpful.

PPM 3 - No sir, only once he had hematuria,

PPM 2 - Why would he have haematuria? Even if only once? Rule out the common stones and stuff (which USG did) and then this becomes significant?

Anything on Urine Microscopy?

I can assure you he won't open up unless you probe a few times. That's how we got to the truth in those 2 cases we saw at SVS

PPM 1 - 👍

PPM 3 - 👍

USG Report.

PPM 2 - No stones, no kidney disease, then this haematuria is coming from the LUT and what differentials would you consider in such cases?

PPM 3 - ? Ureteric caliculi  , may be gone off

PPM 2 - Then he would know if he passes a stone?

Did the haematuria 1 month ago coincide with the beginning of all his symptoms? Then how can a calculus explain GI and systemic symptoms.

08-12-2024

PPM 3 -   

GRBS :

10 am - 232

1pm - 242

3pm - 252

8pm - 255

10pm - 250.

2am - 202

8am - 131

PPM 1 - Taken 1.5mg yesterday?

Also if he has taken 1.5 mg of glimiperide today morning too before breakfast we would need to see his 2 hour post breakfast blood sugars that would be available now.

PPM 3 -  Post breakfast - 289 sir

PPM 1 -  This was after 1.5 mg of glimiperide or 1mg? What's his sugars two hours post lunch?

PPM 3 - He is on GLIMIPERIDE 1 mg, METFORIN 500mg BD sir. No fever spike today sir.

GRBS

4 PM - 367

8 PM - 237

PPM 1 - We asked to increase by 0.5mg yesterday @PPM3!

Please increase to 1.5mg twice daily.

PPM 3 - Ok sir.

09-12-2024

PPM 1 - Today's fever chart and blood sugar update?