General Medicine pratical case 10/01/2022

A case came to casuality with c/o fever since 3 days 
SOB grade 2----> 4 since 2 days 
LL swelling and redness since 1 day.

Patient was apparently asymptomatic 3 days back and then he developed fever which was low grade, intermittent, relieved ontaking medication and not associated with chills and rigor.
He has SOB, No orthopnea or PND or pedal edema or chest pain or palpitations.
He applied ointment for leg pain over right foot and later he developed redness and swelling over right foot and with these complaints they went to outside hospital and on presentation to the outside hospital vitals spO2-74% on RA with BP 70/40. He was put on CPAP and inotrope support and reffered to our hospital

General Examination:
Patient is C/C/C

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
CVS: S1 S2 +
RS: Decreased BAE 
B/l crepts present in IAA and ISA
P/A: soft and non tender
Limb examination:
Investigations
Chest X-ray
ECG:
Day-1 Investigations sent on 8/1/22, 

2D ECHO Report
Abg at 6am:
Abg at 1:40pm :
Diagnosis: 
Sepsis secondary to right lower limb cellulitis 
? Moderate ARDS (PaO2/FiO2= 100)
? Acute PE 
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+


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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