A 70 YEAR OLD MALE WITH FEVER , SOB AND RIGHT LL SWELLING

Arushi Kumari 

Roll number- 151

4th year MBBS

11/01/2022


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 a 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 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 days

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 3 days back and later he developed redness and swelling over right foot (no history of trauma or injury).
- With these complaints they 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. 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.
- Patient was admitted to our hospital ICU on 07/01/22 .
- 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 

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 sign of pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, no  edema .

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 murmur heard 

Resp.system:-  position of trachea :central               Vesicular breath sound 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
       - 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            normal
 (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:





ECG 

Day 1 :








2D- echo report :

ABG at 6:00 a.m

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  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 by

Update: day 2 ( 8/01/2022 )

Post debridememt right Lower limb

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

Drugs used -


Post intubation: 

Abg:

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

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 more than 65mmHg
12. INJ. LASIX 20MG PO OD




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