60 year old male with fever and SOB and Right LL swelling

T. Akshitha Reddy

Roll number- 186

4th year MBBS


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




A 60 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 days

History of presenting illness:

Patient was apparently asymptomatic 3 days back 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 orthopnea or PND or pedal edema or 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 they went to outside hospital and on presentation to the outside hospital vitals 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 conditions was explained and was advised for hemodialysis. But patient attendees was not willing for further investigation and wanted to refer to our hospital.
Past history 
Not a k/c/o Dm,HTN,CAD,asthma,TB

General Examination:

Patient is conscious, coherent and cooperative. Well oriented to time, place and person
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy,no edema

Vitals:
Temp - 100 F
PR- 104 bpm
BP- 100/70mmHg
RR- 28 cpm
SpO2- 97% at RA

Systemic Examination:

CVS: S1 S2 heard
RS: Decreased BAE 
B/l crepts present in IAA and ISA
P/A: soft and non tender

Clinical Images:

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

Post debridememt right Lower limb

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

Drugs used -


Post intubation: 

Abg:


On 9/1/22

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+

Ecg


Cxr


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


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










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