Case No 2

60-year old patient sent from surgery in-patient department for fever

Medical History

Present Illness: A day before yesterday fever values rising to 39.5°C, chill, shivering, sweating and subsequent global weakness. Antipyretics with poor effect. Diarrhoea, vomitus, abdominal pain and dysuria not reported. Cough occurring from time to time, rather whooping, mostly when lying. This morning the patient was dizzy and fell down. He hit on the forehead. No loss of consciousness, he can remember everything. Examined at surgery department, where CT showed normal, sent to infectious disease department due to fever.

FHx: insignificant
EHx: grandson had fevers in the recent past
WSHx: electrician
PM/SHx: h/o CAD of 2 arteries, s/p NSTEMI (non-ST-segment elevation myocardial infarction) anterolaterally administered with PCI on RIA+DES 5 years ago, PCI on RDI with implantation of 3x DES stents, he has followed up by cardiologist, function and kinetics of left ventricle were found satisfactory, heart scintigraphy was performed 3 years ago, s/p atrial fibrillation paroxysm with spontaneous version, DM II type on PAD, metabolic syndrome, hyperlipoproteinemia treated with a statin, s/p renal colic, varicose veins of lower extremities, s/p surgery of umbilical hernia, benign prostatic hyperplasia
Allergies: None, NKDA
Medications: Godasal 100mg 1-0-0 tbl po, Betaloc ZOK 200mg 1-0-0 tbl po, Prestarium Neo 1/2-0-0 tbl po, Rosucard 40mg 0-0-1 tbl po, Glucophage 750mg 0-0-2 tbl po, Duodart 1-0-0 tbl po
Abuse: Non-smoker, alcohol drinking only rarely

Physical Examination

Vital Signs (Vitals): T: 38.6 °C; HR: 89; RR: 20; BP: 85/69; satO₂ 97 % on 2L O₂
Height/ Weight: h 183 cm, m 134 kg. Obese.
General: Patient lying weakened in bed
Psychiatry: Alert and oriented to person, place, and time
Skin: No rash or lesions. Turgor reduced.
Head: Small hematoma on the right forehead.
Eyes: PERRL, EOMI. No scleral icterus.
ENT: No nasal d/c. MMM. Oropharynx clear with no lesions/erythema. Tonsils normotrophic. Tongue with geographical coating.
Neck: No masses. No thyromegaly. No bruits.
Lymph Nodes: No cervical, axillar or inguinal LAD.
Cardiovascular: Rhythm irregular. Heart sounds without murmur. Pulses 2+ equal on both sides, peripheral deficit.
Lungs: Moist rales/crackles on the right hemithorax basally and up to half the chest. Deep breathing provokes nonproductive cough.
Abdomen: soft, non-tender, non-distended. No masses. No rebound/guarding. No hepatosplenomegaly. BS+
Rectal: Rectal exam not performed since no symptoms indicated blood loss.
Extremities: No bilateral cyanosis, clubbing or edema. Varicose veins bilaterally. Calves not tender to palpation. No petechiae. Capillary refill slower.
Musculo-skeletal: Joints flexible without erythema.
Neurological: Cranial nerves II-XII grossly intact. No decrease in strength. No shakes. DTR 2+ symmetrical. No decrease in sensation. Normal sensation throughout.

Laboratory tests

Hematologic tests:

Blood count: WBC: *20.7 10^9/L RBC: 4.98 10^12/L Hgb: 143.0 g/L Hct: 0.423 1/1 MCV: 84.9 fl MCH: 28.7 pg MCHC: 0.338 kg/L PLT: *138.0 10^9/L Pct: 0.160 x10 ml/L
Leucocyte differential: Automated: Nseg: * 0.87 1/1 Ly: * 0.06 1/1 Mo: 0.06 1/1 Eseg: 0.00 1/1 Bas: 0.00 1/1 IG: * 0.01 1/1
Abs. values: Ne#: * 18.0 10^9/L Ly#: 1.3 10^9/L Mo#: 1.2 10^9/L Eo#: 0.0 10^9/L Ba#: 0.0 10^9/L IG#: * 0.2 10^9/L
Microscopically: Ne-seg: 0.72 1/1 Ne-band: 0.18 1/1 Ly: 0.06 1/1 Mo: 0.04 1/1
Hemocoagulation: PT-time: 17.8 s PT-R: * 1.35 1/1 INR: 1.45 1/1 PT-N: 13.2 s aptt-p: 43.2 s aptt-R: * 1.31 1/1 aptt-n: 33.0 s DDi: highly positive, >4.0 !! mg/L FEU

Biochemical tests:

Urine chem.: U-pH: 5.5 U-SG: * 1.033 kg/L U-Glu: 0 arb.j. U-Keto: 0 arb.j. U-Prot: *2 arb.j. U-Bil: 0 arb.j. U-Uro: 0 arb.j. U-Krev: * 2 arb.j. U-Nit: 0 arb.j. U-Ery: * 91 /ul U-Leu: 12 /ul U-VaGr: * 9 /ul U-EpDl: 7 /ul U-EpKu: * 5 /ul U-Hlen: 4 arb.j. U-Na: * 37 mmol/L U-K: * 93 mmol/l dU-Na: 148 mmol/d dU-K: ! 372 mmol/d
Plasma and serum chemistry: Gluk: *7.0 mmol/l Na⁺: 135 mmol/l K⁺: 4.00 mmol/l Cl^-: 101 mmol/l Urea: * 12.90 mmol/l Cr: * 145 umol/l AST: * 1.88 ukat/l ALT: * 0.99 ukat/l ALP: 0.76 ukat/l GGT: 0.74 ukat/l CRP: ! 371.9 mg/l
Astrup: pH: *7.344 pCO₂: 5.85 kPa pO₂: !4.5 kPa BE: -1.2 mmol/l AKTB: 24.1 mmol/l SO₂: *0.609

Microbiological examinations:

Urine - antigen detection: Legionella sp. - antigen: POSITIVE, Str. pneumoniae - antigen: negative
Molecular techniques: Sputum expectorated - bacterial agents of CAP (by the PCR):
Streptococcus pneumoniae negative, Haemophilus influenzae negative, Chlamydophila pneumoniae negative, Mycoplasma pneumoniae negative, Legionella pneumophila POSITIVE, Bordetella pertussis negative, Bordetella parapertussis negative
Molecular techniques: respiratory viruses
Detection of Influenza A virus (subtype A1/A2) RNA PCR negative, Influenza B virus RNA PCR negative
SARS-CoV-2 RNA RT PCR negative
Covid-19 serology: Antigen SARS CoV-2: negative, Anti-nCoV COVID19 IgG CLIA, IgM EL Aut, IgA EL negative
Serology: RPR test negative; TPPA: negative.
HIV serology: HIV-1,2 negative, p24 negative.
Panel of viral hepatitis: markers of VHA, B, C completely negative
Legionella serology: Legionella - antibodies (ELISA) L. pneumophila sv.1-6 IgG: 0,10 - negative L. pneumophila IgM: 0,20 - negative.
Blood culture: 2× negative
Throat swab culture: normal flora
Urine: Quantitating bacteria in midstream clean-voided urine: primo-culture sterile

Imaging and other paraclinical examinations

Imaging:

CT scan of the head: Normal finding.
Chest XR: Describe it for yourself.

Fig 1 Computed tomography (CT) of the head: NAD

Fig 2 Chest XR (lying position)

Electrophysiologic and Functional Examinations:

ECG: atrial fibrillation, HR 98/min, intermediate axis, ventricular complexes narrow.

Diagnostic Conclusion

Detect both main and secondary diagnoses. You should find and write down at least nine ongoing diseases.

Treatment

Select the most appropriate antibiotic.

Questions

No additional questions.