69 Years-Old-Male presenting in the hospital with High Grade Fever and altered sensorium with the history of Rheumatic Heart Disease and double prosthetic valve replacement
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This is a HIPAA de-identified
open-online-patient-record with initial information in patient's voice, posted
here February 2017 after collecting informed patient consent (form downloadable
Click
Here) by BMJ Elective
Student.
According to patient's relative: (Patient's Story)
1. In 1985 patient was presented to a doctor with the complain of muscle pain in leg, shaking fever and after different kind of tests patient was diagnosed with rheumatic heart diease (RHD) followed by valvotomy of the affected valve.
2. In 2007, the patient was unable to digest food properly and met a local doctor. After different kind of tests doctor told that his both valves were damaged and so both should be replaced. After about 4 years, patient underwent second heart surgery with double prosthetic valve replacement.
3. In 2017 (2 days prior to admission), after returning from daily work at night, he could not take normal dinner as he used to take and got suddenly shaking fever. And patient was not able hold his urine in the bed and started talking unusually (altered sensorium).
4. Next day they took the patient to ESI Hospital and they put Urinary catheter and referred to Narayana hrudayalaya hospital, durgapur.
Story that continued after Admission:
1. Patient admitted to hospital with high grade fever and altered sensorium. CT scan of the brain was done (Report below). Oneday after admission, Total WBC count was seen 18100 cells/cumm and he was started on empirically Inj. Meropenam 1 gm (IV) and Acyclovir 500 mg (IV)) but it was then held. Meanwhile, patient's blood & urine were sent for C/S.
2. Urine C/S reported on 3rd day of post- admission which has no growth and blood C/S reported next day which shown growth of Coagulase Negative Staphylococcus.
3. Given patient's past history of double prosthetic valve replacement with current growth of Coagulase negative Staphylococcus in blood culture, it was thought that probably it is an Infective endocarditis and antibiotics Inj. Augmentin was started. Patient's fever went down.
4. O/E, patient also found to have splenomegaly. But in spite of giving antibiotics, patient's total WBC count kept increasing. Then during close observation it was found that patient's differential count of lymphocytes were so high (Lymphocytosis) that made the suspicion of CLL.
Complete Blood Count Progress report:
USG Whole Abdomen Report:
5. Mini mental status examination (MMSE) was 23 out of 30 in this patient. Then peripheral blood smear was ordered for looking the elements of CLL and microscopic images are shown below. And in depth review of previous reports from 2007 shown that his DC-Lymphocyte count was high from 2007 and which was completely missed that time and his operation was done in 2011 whereas it was completely unnoticed.
smudge cells are seen
Reports from 2007 Attached:
Discharge Summary After Valve replacement:
Serology Reports during Admission:
1. Dengue IgG Non-Reactive
2. Dengue IgM Non-Reactive
3. NSI Ag Non-Reactive
Liver Function Test: (Abnormal findings only)
1. Total Proetin 5.8 L
2. Albumin 3.1 L
Diagnosis is still need to be confirmed.
According to patient's relative: (Patient's Story)
1. In 1985 patient was presented to a doctor with the complain of muscle pain in leg, shaking fever and after different kind of tests patient was diagnosed with rheumatic heart diease (RHD) followed by valvotomy of the affected valve.
2. In 2007, the patient was unable to digest food properly and met a local doctor. After different kind of tests doctor told that his both valves were damaged and so both should be replaced. After about 4 years, patient underwent second heart surgery with double prosthetic valve replacement.
3. In 2017 (2 days prior to admission), after returning from daily work at night, he could not take normal dinner as he used to take and got suddenly shaking fever. And patient was not able hold his urine in the bed and started talking unusually (altered sensorium).
4. Next day they took the patient to ESI Hospital and they put Urinary catheter and referred to Narayana hrudayalaya hospital, durgapur.
Story that continued after Admission:
1. Patient admitted to hospital with high grade fever and altered sensorium. CT scan of the brain was done (Report below). Oneday after admission, Total WBC count was seen 18100 cells/cumm and he was started on empirically Inj. Meropenam 1 gm (IV) and Acyclovir 500 mg (IV)) but it was then held. Meanwhile, patient's blood & urine were sent for C/S.
2. Urine C/S reported on 3rd day of post- admission which has no growth and blood C/S reported next day which shown growth of Coagulase Negative Staphylococcus.
3. Given patient's past history of double prosthetic valve replacement with current growth of Coagulase negative Staphylococcus in blood culture, it was thought that probably it is an Infective endocarditis and antibiotics Inj. Augmentin was started. Patient's fever went down.
4. O/E, patient also found to have splenomegaly. But in spite of giving antibiotics, patient's total WBC count kept increasing. Then during close observation it was found that patient's differential count of lymphocytes were so high (Lymphocytosis) that made the suspicion of CLL.
Complete Blood Count Progress report:
5. Mini mental status examination (MMSE) was 23 out of 30 in this patient. Then peripheral blood smear was ordered for looking the elements of CLL and microscopic images are shown below. And in depth review of previous reports from 2007 shown that his DC-Lymphocyte count was high from 2007 and which was completely missed that time and his operation was done in 2011 whereas it was completely unnoticed.
Reports from 2007 Attached:
Discharge Summary After Valve replacement:
Serology Reports during Admission:
1. Dengue IgG Non-Reactive
2. Dengue IgM Non-Reactive
3. NSI Ag Non-Reactive
Liver Function Test: (Abnormal findings only)
1. Total Proetin 5.8 L
2. Albumin 3.1 L
Diagnosis is still need to be confirmed.
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