32 year old male patient with Fever, giddiness, vomiting

 This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed 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 the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

Following is the view of 

CASE

 32 year old male patient came to opd on 20th of august with chief complaints of

▪ FEVER since morning

▪ Giddiness and vomitings since afternoon

 HISTORY OF PRESENTING ILLNESS

 Patient was apparantly asymptomatic 4 days back then he had abrasion on the right leg on 16th for which he had not taken any first aid following which he was asymptomatic for 4 days then he developed 

▪Fever associated with chills on 20th and which was high grade not associated with cold, cough, head ache, shortness of breath and no diurnal variations is seen ▪Pain in the right calf which was dragging in nature radiating to thigh so that patient was not able to walk aggravating on walking and movement of leg and relieved on rest and medication

 For which patient went to rmp where he was given IV fluids following which he had 

▪ Vomiting 1st episode which was non billious, non projectile, and food contents are present not associated with epigastric pain , constipation and loose motions 

after going home he had Giddiness rotational, not associated with headache ,sweating, palpitations, blurring of vision, diplopia, evening and 2nd episode of vomiting and went to rmp then he referred to present hospital

▪ On presentation:- cold extremities present , Pulse- feeble, BP:- 70/40 started on fluid resuscitation

He was kept in ICU and was shifted to general ward on 27th august and patient now complaints of only pain on movement of leg

PAST HISTORY

 Patient had asthma since childhood , exacerbates on exposure to cold and on medication for it

Not a known case of diabetes, hypertension, epilepsy, tuberculosis, any chronic illness

PERSONAL HISTORY 

 Diet:- mixed

 Appetite:- normal

 Bowel and bladder movements:- regular

 Sleep:- adequate

 Addictions:-

   • Alcohol- 4 times a day 1/2 quarter to 1 bottle since 20 years

  •Kaini- daily since 5 years

  • smoking :- occasionally since 20 years

▪No known allergies

FAMILY HISTORY

 not significant

GENERAL EXAMINATION

 •Patient is conscious ,coherent, cooperative , well oriented to time , place ,person

▪Moderately built and moderately nourished

Pallor:- absent

Icterus:- absent 

Cyanosis:- absent 

Clubbing :- absent

Lymphadenopathy:- absent

Edema:- absent

 

VITALS

 

At admission:- (20/08/2021)

Temperature:- 99.4 F

Pulse rate:- 60 bpm( low volume)

Respiratory rate:- 12cpm

BP :- 70/40 mm of hg

Spo2:- 97% at room temp

GRBS:- 96mg%

24/08/2021

BP:- 130/90 mm hg

PR:-95 bpm

GRBS:- 98mg/dl

25/08/2021

Temperature:- 98.6F

BP:- 130/90mm hg

PR:- 65 bpm

26/08/2021

PR:- 64bpm

BP:- 120/90mm of hg

GRBS:-122mg/dl

27/08/2021

PR:-65bpm

BP:-130/80mm hg

28/09/2021

PR:- 72bpm

BP:-120/90mm of hg

SYSTEMIC EXAMINATION

▪CVS- S1 ,S2 hears no added murmurs and thrills

▪Respiratory system:- Normal vesicular breath sounds audible

▪ Abdomen:-obese, tenderness elicited in epigastric hypochondrial region, no palpable mass

▪ Cns:- Intact

INVESTIGATIONS

  HEMOGRAM

 

ECG

ULTRASOUND REPORT

2D Echo

PROVISIONAL DIAGNOSIS

 

Septic shock secondary to right leg cellulitis

 

TREATMENT REGIMEN

 20/08/2021

IVF- NS,RL- 200ml/kg/ hr-------10ml/kg/hr

Inj- ceftriaxone 1gmIV/ BD

Inj- Pantop-80mg mgIV 100 ml NS IV/ stat

Inj-Thiamine 300 mg IV 100ml NS IV/ stat

Inj- ondonsetron 4mg IV / stat

Inj - tramdol 1 AMP 100 ml NS IV/TID

BP,PR -2nd hrly nmiotoring

TEMP charting- 4th hrly

I/O - charting

 

21/08/2021

IV fluids- RL, DNS,NS@200mg/ hr

Inj- ceftriaxone-1gm IV/BD

Inj-PANTOP- 40 mg IV/OD

Inj- Zofer 4mg Iv/sos

Inj - tramdol 1 AMP 100 ml NS IV/BD

Inj- optineuron 1 amp M 100 ml NS IV/OD

Strict I/O charting

BP,PR,TEMP,SPO2- charting

Inj- noradrenaline 20 amp in 46 ml NS

(increase or decrease according to MAP 60-70)

Inj- metrogyl 100 ml Iv/Tid

22/08/2021

 

IV fluids- RL, DNS,NS@200mg/ hr

Inj- ceftriaxone-1gm IV/BD

Inj-PANTOP- 40 mg IV/OD

Inj- Zofer 4mg Iv/sos

Inj - tramdol 1 AMP 100 ml NS IV/BD

Inj- optineuron 1 amp M 100 ml NS IV/OD

Strict I/O charting

BP,PR,TEMP,SPO2- charting

Inj- noradrenaline 20 amp in 46 ml NS

(increase or decrease according to MAP 60-70)

Inj- metrogyl 100 ml Iv/Tid

23/08/2021

 

IV fluids- RL, DNS,NS@200mg/ hr

Inj- ceftriaxone-1gm IV/BD

INJ metrogyl 100 ml iv/ TID

INJ Pan 40 mg iv/ bd

Inj zofer 4mg iv/ Tid

Inj optineuron 1 amp in 100 ml NS Iv / oD

TAB pcm 650 mg TID

Tab chymoral forte Tid

Inj tramadol 1 amp in 100ml NS IV

Temp chartnig and tepid sponging 4th hrly

Stirct I/O charting

Bp, PR, RR, temp ,spo2 monitoring

24/08/2021

 

IV fluids- RL, DNS,NS@200mg/ hr

Inj- ceftriaxone-1gm IV/BD

INJ metrogyl 100 ml iv/ TID

INJ Pan 40 mg iv/ bd

Inj zofer 4mg iv/ Tid

Inj optineuron 1 amp in 100 ml NS Iv / oD

TAB pcm 650 mg TID

Tab chymoral forte Tid

Inj tramadol 1 amp in 100ml NS IV

Temp chartnig and tepid sponging 4th hrly

Stirct I/O charting

Bp, PR, RR, temp ,spo2 monitoring

25/08/2021

 IV fluid with optineuron@ 100 ml/ hr

Inj ceftriaxone 1gm IV /BD

Inj metrogyl 100 ml Iv/TID

Inj pan 40 mg IV / OD

TAB Pcm 650 mg TID

Tab chymoral forte TID

strict I/O charting

BP. PR ,TEMP , spo2 monotoring

Tab ultracet QID( 1/2-1/2-1/2-1/2)

26/08/2021

 

IV fluid with optineuron@ 100 ml/ hr

Inj ceftriaxone 1gm IV /BD

Inj metrogyl 100 ml Iv/TID

Inj pan 40 mg IV / OD

TAB Pcm 650 mg TID

Tab chymoral forte TID

Bp,PR ,TEMP , spo2 monotoring

Tab ultracet QID( 1/2-1/2-1/2-1/2)

27/08/2021

IV fluid with optineuron@ 100 ml/ hr

Inj ceftriaxone 1gm IV /BD

Inj metrogyl 100 ml Iv/TID

Inj pan 40 mg IV / OD

TAB Pcm 650 mg TID

Tab chymoral forte TID

Bp,PR ,TEMP , spo2 monotoring

Tab ultracet QID( 1/2-1/2-1/2-1/2)

28/08/2021

IV fluid with optineuron@ 100 ml/ hr

Inj pan 40 mg IV / OD

TAB Pcm 650 mg TID

Tab chymoral forte TID

Bp,PR ,TEMP , spo2 monotoring

Tab ultracet QID( 1/2-1/2-1/2-1/2)