55/M Pyrexia with ?Septic shock

 NAME: Meghana.M

Roll no: 95

Batch: 2017

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55 year old MALE daily wage laborer by occupation, resident of Mandapuram came with chief complaints of 

Fever  since 10days, 

Abdominal pain Since 10 days, 

Patient was apparently asymptomatic 15 days back then he developed FEVER high-grade Intermittent, Insidious in onset, gradually progressive, decreased on using medications. 

Since day 3 fever was associated With headache, chills and Rigors decreased sleep; decreased intake of food, no nausea. No vomiting, no loose stools. Associated with myalgias and arthralgias, Aggravated at Night, relieved on taking medications

And ABDOMINAL PAIN, in umbilical region 

Squeezing type, Insidious in onset, Aggravated on oral intake of food and relieves 15 mins later automatically. Passage of green color stools since 6 days, 

Associated with foul smell, mucoid small in quantity

Each episode of stool preceeded by pain abdomen in hypogastric region

Past history: 

Not a known case of diabetes, hypertension, tuberculosis, epilepsy, bronchial asthma,  CAD CVD

No surgeries or blood transfusions

Personal history.

Diet mixed

Appetite decreased 

Sleep adequate

Bladder normal

Bowel: regular; green stools since 4 days

Addictions: 

Chronic alcoholic 

Beedis 4-5/day

Family history.

Not significant.

General examination:

Patient is conscious coherent cooperative 

Bp: 100/70mm hg

PR: 108 bpm

Rr:  22 cpm

Spo2: 96% on Ra 

Temperature: 98.9 F

GRBS: 120 mg/dl at 5pm

No pallor, icterus, clubbing, lymphadenopathy, or oedema of feet 

Systemic examination:

CVS S1/S2 heard

RS bilateral air entry present, normal, vesicular breath sounds heard

PA: soft, non tender, 

No palpable masses hernial orifices normal

No bruits

Bowel sounds heard

CNS: 

He is conscious, coherent, cooperative

GCS E4V5M6. 

Motor power:.    UL.         LL

   R                     5/5         5/5

   L                      5/5         5/5

Tone normal in all 4 limbs.

Reflexes:.     

           B     T     S     A    K     P

    R.   2+   2+   2+  2+   2+   Flexor

    L.   2+   2+   2+  2+   2+    Flexor

 Cerebellar signs:

Finger nose in coordination: yes 

Knee heel in coordination: yes

COURSE IN HOSPITAL:

55 YR OLDMALE CAME TO OPD WITH ABOVE MENTIONED COMPLAINTS PATIENT HAD FEVER SPIKES AND HYPOTENSION WITH TACHYCARDIA

ABG 4/3/23

PH; 7.45

PCO2; 26.7 MMHG 

P02; 80.1 MM HG 

HCO3: 18.0 MMOL/L

TREATED WITH 

1. INJECTION CEFTRIAXONE 1000MG (DAY 3)

2. CAP DOXYCYCLINE 100MG

3. INJ FALCIGO 3 DOSES GIVEN

ON 5/3/23 

BP. 80.50 MM HG, INJ.NORAD 5ML/HR STARTED 

INJ MEROPENEM GIVEN ;

ABG ON 5/3/23 

PH: 7.126

PCO2: 19.7 MM HG

P02: 51.3MM HG

S02:  92.7

HCO3: 6.2 mmol/L

INJ. 50mEq  H2CO3 given

INJ 100mEQ H2CO3 given IN 100ML NS OVER 1 HR

ON 6/3/23

 BP 90/60 MM HG ON INJ. NORAD 14ML/Hr 

STARTED ON INJ.VASO 1.6ML/hr

 ABG ON 6/3/23

PH: 7.13

PCO2; 22.1 MM HG 

P02; 51.6 mm HG

HC03: 7.1 mmol/L

S02: 89.3

CHEST RAY;

NO ABNORMALITY

CULTURES;

BLOOD C/S; NO GROWTH 

URINE C/S; NO GROWTH 

STOOL C/S: NORMAL INTESTINAL FLORA

INVESTIGATIONS:

2DECHO;

EF;64 NO MR/AR/TR

NO RWMA NO AS/MS

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION PRESENT. NO PAH/PE

USG ABDOMEN;

HEMANGIOMA IN SEGMENT 6 OF LIVER

RIGHT RENAL CALCULI 4MM IN LOWER POLE OF RIGHT KIDNEY

MILD SPLENOMEGALY

Hemogram.

CUE.

BGT.

LFT 

RFT.

S.urea: 39 mg/dl 

S. Creatinine: 1.2 mg/dl

S.electrolytes: 

Sodium: 132 mEq/L

Potassium: 3.9 mEq/L

Chloride: 96 mEq/L

Calcium ionised: 0.96 mmol/L

DENGUE ANTIGEN:

Chest x-ray

SEROLOGY: 

HIV: negative

Hbsag: negative

Rpr: negative

Anti HCV AB: negative 

ECG: 

PROVISIONAL DIAGNOSIS: ?SEPTIC SHOCK SECONDARY TO ENTERIC FEVER ? CLINICAL MALARIA 

Treatment:

03/03/2023:

1. IV NS BOLUS STAT 

2. IV NS 100ml/hr 

3. Inj. PCM 500mg IV SOS

06/03/23:

IV FLUIDS NS 100ml/hr

Inj CEFTRIAXONE 1Gm/Iv/Bd

Inj. FALCIGO 120mg IV @ 0 , 12, 24, 48

Inj. PAN 40mg iv od

Inj Neomol 1gm, iv/sos if temp>101F

Inj. Norad iv/ 14ml/hr 

Inj zofer 4mg iv bd

Tab. Doxy 100mg po bd

Tab dolo 650 mg po qid

Tepid sponging + ice packs 

LAMANOTES;

THIS IS A CASE OF 55 YR OLD MALE WITH PYREXIA UNDER EVALUATION  ?SEPTIC SHOCK SECONDARY TO 

?ENTERIC FEVER 

?TOXIN MEDIATED ALI 

? CLINICAL MALARIA 

PATIENT ATTENDERS WERE EXPLAINED ABOUT PATIENT’S CONDITION, NEED FOR FURTHER EVALUATION AND TREATMENT AND COMPLICATIONS, RISK AND POOR PROGNOSIS EXPLAINED IN THEIR OWN LANGUAGE

PATIENT ATTENDER UNDERSTOOD THE ABOVE AND DESPITE

THAT PATIENT ATTENDERS LEFT AGAINST MEDICAL ADVICE