45 year old male, driver by occupation with chief complaints of fever since 12 days, Vomitings since one day
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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 competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 45 year old male driver by occupation came to casualty with chief complaints
Fever since 12 days
Vomitings since one day
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 12days back then he had fever ,which is intermittent with evening rise of temperature which relieves on taking medication associated with chills and rigor
Vomitings one episode per day since one day, non bilious, non projectile , content food particles
No h/0 abdominal pain, headache, Burning micurition, sweating
Patient is a Rice mill driver by occupation, patient had night shift the previous day came at morning 10:00am then ate idli as his breakfast then had loss of appetite and did vomiting which was non bilious, non projectile. Patient took medication for fever since 5days. Patient had a nap in the afternoon, again found evening rise in temp took medication went to local hospital they referred to higher centre in view of non recordable blood pressure
PAST HISTORY:
Patient is not a known case of HTN, DM, Asthma
FAMILY HISTORY:
Not significant
PERSONAL HISTORY:
Patient goes to work at 6 in morning works till 10 am, eats his breakfast at 9:00am (local food), returns to home for lunch (rice ) sleeps for 2 hours ,goes to work again at 4 pm returns to home at 9:00pm eats his dinner, then has his alcohol session 180ml whiskey since 2months daily ,previously he used to drink only on weekends.
GENERAL EXAMINATION:
Patient is conscious, coherent, co operative
Vitals at admission :
GCS : E4V5M5
Temperature: 98F
Pulse rate : 80bpm
Respiratory rate: 16Cpm
BP : Not recordable
Spo2 : 95
GRBS :134
Cardiovascular system:
S1, S2 heard
No murmurs
Respiratory system:
Bilateral air entry present
Normal vesicular breath sounds
Per abdomen :
Soft , non tender
Bowel sounds present
Central nervous system :
NAD
INVESTIGATIONS:
Arterial blood gas :
pH -7.465
pCO2 -29.6mm hg
pO2 - 87.8 mm hg
ctHb - 11.9g/dL
sO2 -95.9%
cHCO3 - 23.1mmol/L
Hemogram :
Haemoglobin -12.0gm/dL
Total count - 25,800cells/cumm
Neutrophils -87
lymphocytes-O5
Eosinophils-03
Monocytes -05
Basophils -00
PCV -36.7vol%
RBC count - 3.79 millions/cumm
COMPLETE URINE EXAMINATION:
Colour -pale yellow
Appearance -clear
Reaction -Acidic
Specific gravity - 1.010
Albumin -
RBS:
127 mg/dL
Blood urea :
28mg/dL
Serum creatinine:
2.2 mg/dL
Serum electrolytes :
Sodium - 139mEq/L
Potassium- 3.6 mEq/L
Chloride - 102 mEq/L
Ultrasound abdomen :
E/o 6.6X4.1cm well defined heteroechoic collection notes in the right lobe of liver with thin internal echoes
Likely suggestive of liver abscess with poor liquifaction
Grade 2 Fatty liver with mild hepatomegaly
Blood grouping and RH type :
AB POSITIVE
APTT :
37 sec
PROTHROMBIN TIME :18sec
SPOT URINE PROTEIN :8.5
SPOT URINE CREATININE :65
SPOT URINE PROTEIN/CREAT RATIO:0.13
FEVER CHART :
INR : 1.33
DIAGNOSIS:
? HYPOVEMIC SHOCK SECONDARY TO DEHYDRATION
?HYPOVOLEMIC SHOCK SECONDARY TO SEPSIS WITH PRE RENAL AKI WITH LIVER ABSCESS (SIZE 6.6X4.1 CM)
TREATMENT :
1)BP was non recordable when he was brought to casualty then 1pint of NS was given at 10:10pm, BP still was non recordable then another pint of NS was given at 10:30 PM, Then BP was around 60/50mm hg at 10:50PM, another pint of NS, BP -80/50mm hg at 11:15 PM, then at 11:35 PM BP -80/50MM hg then 1pint of NS @125 ml/hr was continued
2)1AMP KCL in NS at 70ml / hr
3)INJ PIPTAZ 4.5gm X IV STAT
4)BP MONITORING EVERY HOURLY
6)GRBS 6th hourly monitoring
7)Strict I/O Charting
A 45 year old male driver by occupation came to casualty with chief complaints
Fever since 12 days
Vomitings since one day
DOA 2/05/2022
ICU BED 1, SOAP NOTES DAY 1 :
S
Fever got subsided
O
Patient is conscious, coherent, co operative
Vitals at admission :
GCS : E4V5M6
Temperature: 98F
Pulse rate : 80bpm
Respiratory rate: 16Cpm
BP : 90/60 mm hg @6ml/hr (nor ad)
Spo2 : 95
GRBS :134
Cardiovascular system:
S1, S2 heard
No murmurs
Respiratory system:
Bilateral air entry present
Normal vesicular breath sounds
Per abdomen :
Soft , non tender
Bowel sounds present
Central nervous system :
NAD
INVESTIGATIONS:
Arterial blood gas :
pH -7.465
pCO2 -29.6mm hg
pO2 - 87.8 mm hg
ctHb - 11.9g/dL
sO2 -95.9%
cHCO3 - 23.1mmol/L
Hemogram :
Haemoglobin -12.0gm/dL
Total count - 25,800cells/cumm
Neutrophils -87
lymphocytes-O5
Eosinophils-03
Monocytes -05
Basophils -00
PCV -36.7vol%
RBC count - 3.79 millions/cumm
RBS:
127 mg/dL
Blood urea :
28mg/dL
Serum creatinine:
2.2 mg/dL
Serum electrolytes :
Sodium - 139mEq/L
Potassium- 3.6 mEq/L
Chloride - 102 mEq/L
Ultrasound abdomen :
E/o 6.6X4.1cm well defined heteroechoic collection notes in the right lobe of liver with thin internal echoes
Likely suggestive of liver abscess with poor liquifaction
Grade 2 Fatty liver with mild hepatomegaly
Blood grouping and RH type :
AB POSITIVE
APTT :
37 sec
PROTHROMBIN TIME :18sec
INR : 1.33
A
? HYPOVEMIC SHOCK SECONDARY TO DEHYDRATION
?HYPOVOLEMIC SHOCK SECONDARY TO SEPSIS WITH PRE RENAL AKI WITH LIVER ABSCESS (size 6.6X4.1cm)
P
1)BP was non recordable when he was brought to casualty then 1pint of NS was given at 10:10pm, BP still was non recordable then another pint of NS was given at 10:30 PM, Then BP was around 60/50mm hg at 10:50PM, another pint of NS, BP -80/50mm hg at 11:15 PM, then at 11:35 PM BP -80/50MM hg then 1pint of NS @125 ml/hr was continued
2)1AMP KCL in NS at 70ml / hr
3)BP MONITORING EVERY HOURLY
4)GRBS 6th hourly monitoring
5)Strict I/O Charting
A 45 year old male driver by occupation came to casualty with chief complaints
Fever since 12 days
Vomitings since one day
DOA 4/05/2022
ICU BED 1, SOAP NOTES DAY 3 :
S
No fever spikes
O
Patient is conscious, coherent, co operative
Vitals at admission :
GCS : E4V5M6
Temperature: 98F
Pulse rate : 92bpm
Respiratory rate: 16Cpm
BP : 90/60 mm hg
Spo2 : 98
Cardiovascular system:
S1, S2 heard
No murmurs
Respiratory system:
Bilateral air entry present
Normal vesicular breath sounds
Per abdomen :
Soft , non tender
Bowel sounds present
Central nervous system :
NAD
INVESTIGATIONS:
Hemogram :
Haemoglobin -11.6gm/dL
Total count - 14,200cells/cumm
Neutrophils -74
lymphocytes-16
Eosinophils-04
Monocytes -06
Basophils -00
PCV -35vol%
RBC count - 3.60 millions/cumm
A
? HYPOVEMIC SHOCK SECONDARY TO DEHYDRATION
?HYPOVOLEMIC SHOCK SECONDARY TO SEPSIS WITH PRE RENAL AKI WITH LIVER ABSCESS
P
1)INJ METROGYL 750mg IV TID
2)INJ CEFTRIAXONE 2gm IV BD
3)INJ ZOFER 4mg IV BD
4)INJ PAN 40mg IV OD
5)IVF NS , DNS,RL @10ml /hr
6)MONITOR IO CHARTING
7)MONITOR BO HOURLY
8)INJ NORADRENALINE 2AMP IN 50ML NS @10ml/hr
A 45 year old male driver by occupation came to casualty with chief complaints
Fever since 12 days
Vomitings since one day
DOA 5/05/2022
ICU BED 3 , SOAP NOTES DAY 4:
S
Fever spikes since yesterday 8pm
No fresh complaints
O
Patient is conscious, coherent, co operative
Vitals at admission :
GCS : E4V5M6
Temperature: 99F
Pulse rate : 82bpm
Respiratory rate: 16Cpm
BP : 110/80 mm hg
Spo2 : 98
Cardiovascular system:
S1, S2 heard
No murmurs
Respiratory system:
Bilateral air entry present
Normal vesicular breath sounds
Per abdomen :
Soft , non tender
Bowel sounds present
Central nervous system :
NAD
INVESTIGATIONS:
Hemogram :
Haemoglobin -11.6gm/dL
Total count - 14,200cells/cumm
Neutrophils -74
lymphocytes-16
Eosinophils-04
Monocytes -06
Basophils -00
PCV -35vol%
RBC count - 3.60 millions/cumm
SERUM ELECTROLYTES:
Sodium 138mEq/L
Potassium 3.9mEq/L
Chloride 99mEq/L
A
LIVER ABSCESS ?AMOEBIC PRE RENAL AKI (resolving)
HYPOVOLEMIC SHOCK
P
1)INJ METROGYL 750mg IV TID
2)INJ CEFTRIAXONE 2gm IV BD
3)INJ ZOFER 4mg IV BD
4)INJ PAN 40mg IV OD
5)IVF NS , DNS,RL @10ml /hr
6)MONITOR I/O CHARTING
7)MONITOR BP HOURLY
8)MONITOR TEMPERATURE
A 45 year old male driver by occupation came to casualty with chief complaints
Fever since 12 days
Vomitings since one day
DOA 6/05/2022
ICU BED 3 , SOAP NOTES DAY 5:
S
No fever spikes
No fresh complaints
O
Patient is conscious, coherent, co operative
Vitals at admission :
GCS : E4V5M6
Temperature: 99F
Pulse rate : 121bpm
Respiratory rate: 16Cpm
BP : 90/60 mm hg
Spo2 : 98
GRBS @8am :118mg/dL
Cardiovascular system:
S1, S2 heard
No murmurs
Respiratory system:
Bilateral air entry present
Normal vesicular breath sounds
Per abdomen :
Soft , non tender
Bowel sounds present
Central nervous system :
NAD
INVESTIGATIONS:
Hemogram :
Haemoglobin -11.6gm/dL
Total count - 14,200cells/cumm
Neutrophils -74
lymphocytes-16
Eosinophils-04
Monocytes -06
Basophils -00
PCV -35vol%
RBC count - 3.60 millions/cumm
SERUM ELECTROLYTES:
Sodium 140mEq/L
Potassium 3.8mEq/L
Chloride 101mEq/L
A
LIVER ABSCESS ?AMOEBIC PRE RENAL AKI (resolving)
HYPOVOLEMIC SHOCK
P
1)INJ METROGYL 750mg IV TID
2)INJ CEFTRIAXONE 2gm IV BD
3)INJ ZOFER 4mg IV BD
4)INJ PAN 40mg IV OD
5)IVF NS , DNS,RL @100ml /hr
6)MONITOR I/O CHARTING
7)MONITOR BP HOURLY
8)MONITOR TEMPERATURE
9)TAB DOLO 650mg TID
10)INJ NEOMOL 1gm IV/STAT
