60 year old male with fever and SOB and Right LL swelling since 3days

Anigani Kavya

Roll number- 06

4th year MBBS

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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.

General Examination:

Patient is conscious, coherent and cooperative. Well oriented to time, place and person

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, 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:

Investigations:

Cxr:

MRI:

Ecg:

 Day-1 Investigations sent on 8/1/22, 

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:

Ecg:

On 9/1/21

Day 3

S: NO fever spikes

O: pt intubated and is on mechanical ventilator

ACMV PC 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 consciousness

B/L pupil reacting to light

Bp : 100/70mmhg

PR : 82 bpm

Spo2 : 100% on fio2 100

Grbs:121

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