A 70 YR OLD MALE WITH FEVER , SHORTNESS OF BREATH AND RIGHT LOWER LIMB SWELLING

11/1/2022

Name : G Meghana

Roll number- 161

MBBS 4 TH YR ( 9 th semester ) 


" This is an online E-log book to discuss our patient de-identified health data shared after taking his/ her guardians sign 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 those patient clinical problem with collective current best evidence based inputs.

This E-log also reflects my patient centered online learning portfolio.

Your valuable inputs on comment box is welcome

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

CASE:-

A 70 year old male patient from Dhamera village came to casuality with 

Chief complaints :-

-Fever since 3 days

-SOB grade 2----> 4 since 2 days 

-Right LL swelling and redness since 1 day

History of presenting illness:

- Patient was apparently asymptomatic 3 days back before admission to hospital  and then he developed fever which was low grade, intermittent, relieved on taking medication and not associated with chills and rigor.
                                          🠗

- He has SOB (grade 2 which later progressed to grade 4)
                                          🠗

- No associated  orthopnea ,PND ,pedal edema ,chest pain or palpitations.
                                                                                      🠗

- He applied ointment for leg pain over right foot 3days back and later he developed redness and swelling over right foot (no history of trauma or injury)
                                            🠗

- With these complaints the patient  went to a hospital and on presentation at the hospital  His vitals were :- spO2-74% on RA with, BP 70/40 and decreased urine output
                                            🠗

All necessary Investigations were done and he was treated with IV Antibiotics, IV antacids, IV nebulization, IV iontropes, IV multivitamins, He was put on CPAP, and his condition was explained and was advised for hemodialysis. But patient attendees were not willing for further investigation and wanted to refer to our hospital. Patient was admitted to our hospital ICU  on 7/1/2022
                                            🠗

No H/O vomitings , loose stool , pain abdomen, cough or cold.

Past history :-
Not a k/c/o DM,HTN,CAD,Asthma,TB

Personal History :-
  • Diet - mixed 
  • Appetite - normal 
  • Sleep - adequate
  • Bowel and bladder movements :- normal 
  • No known allergies to food or drugs 
  • Addictions - smokes 9 beedis / day 

Family history :-
No significant family history 

General Examination:

- Patient was examined in a well lit room and having taken his informed consent . 
Patient is conscious, coherent and cooperative, Well oriented to time, place and person

-No signs of  pallor, icterus, cyanosis, clubbing,  lymphadenopathy or oedema

  • Vitals( at the time of examination ):-
  • Temp - 100 F
  • PR- 104 bpm
  • BP- 100/70mmHg
  • RR- 28 cpm
  • SpO2- 97% at RA

Systemic Examination:

CVS: S1 S2 heard
         No thrills or murmurs heard 

Resp.system:-  position of trachea : central 
Vesicular breath sounds heard 
No wheezing or dyspnoea 
 Decreased BAE 
B/l crepts present in IAA and ISA

  • P/A: soft and non tender
  •         Shape of abdomen :scaphoid
  •         No palpable mass , hernial orifices , free fluid seen 
  • No signs of organomegaly 

CNS examination :-
  • State of consciousness : conscious 
  • Speech : normal 
  • No signs of meningeal irritation

  • Cranial nerves : intact

Sensory system :- 
  • Pain - Normal 
  • Touch- fine touch - normal
  •       crude touch - normal
  • Temp - normal
  • Vibration - normal
  • Joint position - normal
 
Motor system -. Right                 Left 

Bulk -.        Normal                           N jiormal
( on inspection and palpation. )         

Power -           

Neck.        Good                                      Good

Upper limb.  5/5                                5/5

Lower limb.   3/5.               3/5(on admission)                              
Trunk muscles. Good.                 Good

Tone - 

Upper limb   normal                          Normal 
Lower limb  Normal                          Normal

Reflexes :-
Biceps           +                                    +
Triceps           +.                                   +
Supinator       +.                                   +
Knee.              +.                                   +
Ankle.               +.                                  +
Flexor.           Plantar.                   Plantar 

Finger nose in coordination - no 
Heel knee in coordination - no


Clinical Images:




















Investigations :
Chest x ray:
MRI


ECG

Day 1:-
 


2D echo report:-
ABG at 6am: 
ABG at 1.40 pm:
Fever chart :-

Diagnosis:-
 
Sepsis secondary to right lower limb cellulitis

?Moderate ARDS (PaO2/FiO2= 100)

Pre renal AKI and ? Ischemic hepatitis 

? Lumbar spondylosis (L2 to L5).

Treatment:

1. Propped up posture 

2. O2 inhalation at 8 to 10 L/min 

Maintain spO2 > 90%

3. BIPAP 4th hourly 

4. Inj. PIPTAZ 4.5g /IV /stat 

To inj. PIPTAZ 2.25g IV QID

5. INJ. CLINDAMYCIN 600MG IV TID 

6. INJ. PAN 40MG IV OD

7. INJ. ZOFER 4MG IV BD

8. INJ. PCM 1G IV SOS 

9. T. PCM 650MG PO TID 

10. IVF NS and RL at U.O + 50 ml/hr

11. INJ. NORADRENALINE at 8 ml/hr to increase or decrease acc to MAP > 65 MMHG

12. INJ. LASIX 20MG PO OD 

Update: day 2(8/1/2022)

Post debridememt right Lower limb

Patient was intubated I/v/o 
 type 1 respiratory failiure and Respiratory distress 

Drugs used -
Post intubation: 
Abg:
UPDATE  : Day 3:-

S: NO fever spikes

O: pt intubated and is on mechanical ventilator

 ACMVPC mode

Peep 7

Fio2 100

I:E 1:2

Pt is still on ionotropes noradrenaline @16ml/hr

Vasopressin @1.5ml/hr

Pt sedated and paralysed, on dexmedetomidine 10ml/hr

Atracurium 5ml/hr

 intermittent regaining of consciousnes
B/L pupil reacting to light

Vitals

  • Bp : 100/70mmhg
  • PR : 82 bpm
  • Spo2 : 100% on fio2 100
  • Grbs:121

Systemic Examination 

Cvs : s1s2+

Rs: b/L basal crepts +

P/A : soft,bs+


chest X Ray :- 


Treatment:

Rt feeds 200ml milk +free water 2nd hourly
IV fluids @75ml/hr
1. Propped up posture 
2. O2 inhalation at 8 to 10 L/min 
Maintain spO2 > 90%
3. BIPAP 4th hourly 
4. Inj. PIPTAZ 4.5g /IV /stat 
To inj. PIPTAZ 2.25g IV QID
5. INJ. CLINDAMYCIN 600MG IV TID 
6. INJ. PAN 40MG IV OD
7. INJ. ZOFER 4MG IV BD
8. INJ. PCM 1G IV SOS 
9. T. Paracetomol 650MG PO TID 
10. IVF NS and RL at U.O + 50 ml/hr 
11. INJ. NORADRENALINE at 8 ml/hr to increase or decrease acc to MAP > 65 MMHG
12. INJ. LASIX 20MG PO OD

  UPDATE : On 10/01/22

S :fever spike observed

O: pt intubated and is on mechanical ventilator

 ACMV pC mode

Peep 7

Fio2 60%

I:E =1:2

Pt is still on ionotropes noradrenaline @16ml/hr

Vasopressin @1.5ml/hr

Vitals:

Bp : 110/70mmhg
PR : 102 bpm
Spo2 : 100% on fio2 60%
Rr :14/min

Systemic Examination :

Cvs : s1s2+

Rs: b/L basal crepts +

P/A : soft,bs+
Treatment:

Rt feeds 200ml milk +free water 2nd hourly

IV fluids @75ml/hr

1. Propped up posture 
2. O2 inhalation at 8 to 10 L/min 
Maintain spO2 > 90%
3. BIPAP 4th hourly 
4. Inj. PIPTAZ 4.5g /IV /stat 
To inj. PIPTAZ 2.25g IV QID
5. INJ. CLINDAMYCIN 600MG IV TID 
6. INJ. PAN 40MG IV OD
7. INJ. ZOFER 4MG IV BD
8. INJ. PCM 1G IV SOS 
9. T. Paracetomol 650MG PO TID 
10. IVF NS and RL at U.O + 50 ml/hr
11. INJ. NORADRENALINE at 8 ml/hr to increase or decrease acc to MAP > 65 MMHG
12. INJ. LASIX 20MG PO OD

Update :11/1/2022

S: fever spikes+
passed stools 
    
O: pt intubated and is on mechanical ventilator SIMV PC mode 
Peep 7
Fio2 45
I:E 1:2.4
RR 16
Pt is still on ionotropes noradrenaline @9ml/hr
Vasopressin @1.4ml/hr


  •  intermittent regaining of consciousness
  • taking spontaneous breaths
  • B/L pupil reacting to light
  • Bp : 100/70mmhg
  • PR : 72 bpm
  • Spo2 : 100% on fio2 40
  • Grbs:152
  • Cvs : s1s2+
  • Rs: b/L basal crepts +
  • P/A : soft,bs+

A:Diagnosis: 
Sepsis secondary to right lower limb cellulitis with MODS
? Moderate ARDS (PaO2/FiO2= 100)
? Acute PE 
Pre renal AKI and ? Ischemic hepatitis 
? Lumbar spondylosis (L2 to L5).

Treatment:

Rt feeds 200ml milk +free water 2nd hourly
IV fluids @75ml/hr
1. Propped up posture 
2. O2 inhalation at 8 to 10 L/min 
Maintain spO2 > 90%
3. BIPAP 4th hourly 
4. Inj. PIPTAZ 4.5g /IV /stat 
To inj. PIPTAZ 2.25g IV QID
5. INJ. CLINDAMYCIN 600MG IV TID 
6. INJ. PAN 40MG IV OD
7. INJ. ZOFER 4MG IV BD
8. INJ. PCM 1G IV SOS 
9. T. PCM 650MG PO TID 
10. IVF NS and RL at U.O + 50 ml/hr
11. INJ. NORADRENALINE at 8 ml/hr to increase or decrease acc to MAP > 65 MMHG
12. INJ. LASIX 20MG PO OD



























 



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