04-01-2025
This is an Online E Log Book to discuss our patient's de-identified health data shared after taking her 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 a 64 year old female who was healthy till 2 yrs back became sick when she visited Kedarnath along with her family of husband, son, daughter-in-law and two grandsons. Unfortunately the husband and herself were having frequent bouts of fever and slowly the husband became paralytic and both were given antibiotic IV for fever. At first the elder grandchild also suffered with fever and was fine after proper medication.
The 64F patient's health deteriorated slowly with other clinical problems like weakness, fatigue and gastric problem for which she was advised endoscopy but neglected. This problem aggravated since 4-5 years back. She was given medication for her gastric problem.
The patient is N/K/C/O hypertension and diabetes mellitus. The patient experienced fever for every 10 - 15 days. She could not sleep well when with fever and became weak and inactive. Was advised dolo 650. Recently 15 days back she had viral infection and was prescribed antibiotic. She lost weight with complaints of backache and body pains. She was also advised cardiology tests.
02-01-2025
Afternoon session:
64F with chronic abdominal pain, intermittent fever since two years after a trip to Kedarnath with marked reduced appetite since three months.
On examination an enlarged spleen on palpation and on cardiovascular auscultation a pan systolic murmur by @PPM3.
Caretaker -
Caretaker - Temperature 99.01 at 12.27pm
PPM 1 - Were they able to go to KIMS LB nagar for her trans esophageal echocardiography today?
They are supposed to also share her four hourly fever chart.
Monday appointment fixed sir.
05-01-2025
Caretaker - 99.08 at 6.30pm, with chills.
PPM 1 - Please let us know every four hours even if she doesn't feel it.
Caretaker - Ok sir.
06-01-2025
Caretaker - 37.2 C
PPM 1 - Every four hours.
Caretaker - Ok sir.
Temperature 38.1C at 15.02pm
PPM 1 - Did she eat the whole plate?
Caretaker - Yes sir.
Temperature at 17.38pm is 36.4 C. After medication.
PPM 1 -
Update:
Shared by @PPM4 today
There's a suspicious vegetation in her pulmonary valve👇
And very interestingly a very high pressure gradient proximal to the pulmonary valve also seen in DCRV as recorded by @PPM4 and team here 👇
PPM 1 - Share the fever every four hours before taking the medication.
Caretaker - Ok sir.
Caretaker - No sir.
PPM 1 - Did they do any TT echo there? They have mentioned plan for TEE. Have they given a date for TEE?
Caretaker - @PPM5 also said pulse rate is high, she did 2d echo sir.
PPM 1 - Yes they may have done a transthoracic echo TTE just like we did and planned for trans esophageal echocardiography TEE for which we sent you there. Have they given any date for the TEE?
PPM 1 - Alright
You mean they said TEE could not be done now.
Caretaker - Yes sir.
PPM 1 - Is she eating all these entire plates?
Caretaker - Yes sir.
07-01-2025
Caretaker - Temperature at 7.09am is 37.1C
Caretaker - Temperature at 11.37am is 35.7C
Caretaker - Temperature at 4.32pm is 37.3C.
Tea at 4.33pm.
Caretaker - Dinner at 7.25pm.
Caretaker - 36.5C at 7.18am.
PPM 1 - 👍
Caretaker - 37.9 C at 11.26am.
38.6 C at 15.21pm.
Caretaker - Doctor the patient is suffering a lot with fever at night time. @PPM6 said TEE test is not possible for her, any alternative for her sir? Or any medication you can suggest. 🙏
PPM 1 - Yes the diagnosis for her is closely resembling subacute infective endocardidtis.
Here's a simple explanation of the disease that we suspect is affecting her. 👇
You can meet @PPM5 locally in LB Nagar to start her on therapy and I will let her decide the choice of the individual components of the therapy.
09-01-2025
Caretaker - At 7 am 36.8C, 11am 37.4C
15-01-2025
Caretaker - At 3 pm the temperature is 38.3C
At 7 pm 38.4C
10-01-2025
PPM 1 - Did she sleep after that?
Caretaker - No sir. She is not well.
PPM 1 - She was supposed to visit the hospital for the TEE today?
Caretaker - Yes sir.
I informed @PPM5. Today she is not coming.
PPM 1 - How is she feeling?
Caretaker - 7 am 37.7C. Not well sir.
PPM 1 - We need to start her on treatment once you get the investigations done by @PPM5.
Caretaker - Ok sir.
11 am 37.4 C
3pm 36.7 C
7pm 38.5 C
Today the patient had 300ml Sapota juice.
PPM 1 - Juice with sugar?
Caretaker - No Sir. Fruits and milk.
Caretaker - Treatment started sir. IV Monocef 1 gm twice daily.
PPM 1 - 👍
21-01-2025
Caretaker - Doctor, the patient's five days course is completed and she is having bleeding from her anus. This is for your information.
PPM 1 - Did she have bleeding from anus earlier?
If it hasn't happened before, we need to show a surgeon to rule out piles.
Please share the pictures of all the medicines that she has been taking.
Caretaker - She had piles also sir. But it subsided since 2months, again the problem started with this treatment.
PPM 1 - Piles known since when?
Caretaker - Since1 year sir.
PPM 1 - 👍
PPM 1 - @PPM3 how long would you recommend iv ceftriaxone for her. Currently she's having anal bleeding although she has had piles since long but again she would need to get it locally checked again.
22-01-2025
PPM 1 - @PPM3 may have recommended the ceftriaxone iv twice daily for 2- 4 weeks with the local doctor but there are challenges to this prolonged therapy such as repeated changing of iv line etc
How's her fever been since she began the iv ceftriaxone? Off course if she has another fever this time we may also need to consider thrombophlebitis as a cause rather than just infective endocarditis.
Caretaker - No fever sir.
29-01-2025
Caretaker - 2 weeks course completed sir.
[29/01, 17:33] Patient Advocate 64F Suspected SBE: Good evening, sir, patient name ..., completed two week course, updates : she is weak, she is suffering with piles, getting shivering also, please guide me, sir.
[29/01, 19:03]: Is there a detailed case report link to her illness?We don't keep our patient's names to protect their privacy and confidentiality and hence cannot unlock their records by name but can trace their links to the special PaJR groups we may have created for them earlier if they have agreed.
Completed two weeks of what course?
[29/01, 19:05]: Oh ok.
Now I got it.
Who is looking after her iv antibiotic therapy?
It would have been good if her daily details were shared in the group.
How were they giving the iv? Were they using a cannula?
PPM 1- Has she recently had any bleeding from her piles?
Caretaker - No bleeding sir.
@PPM3 would you like to review her in your OPD?
PPM 3 - Yes sir.
PPM 3 - Any more fever spikes?
PPM 1 - 👍
PPM 3 - Get her to the hospital once.
Caretaker - Ok sir.
25-02-2025
PPM 1 - How is she? Please update.
Caretaker - She is Ok sir. No fever, since last three days she is getting rashes on legs, herhemoglobin is 5.8. Blood transfusion is going on sir. I will update all reports. We did ANA profile, report negative.
🙏
[22-03-2025 07.11] Caretaker: She is no more, thanks for all your efforts, 🙏, please close the announcement group,
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