55 year old female with septic shock
roll no: 55
I've 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 my case:
A 55 year old female who is an agricultural labourer came to the casualty with chief complaints of no urine output since one day.
History of present illness:
Patient was apparently asymptomatic 2 days back then she had 10 episodes of vomiting which was non bilious, non projectile and with food as content, and history of loose stools.
She went to a local RMP in the next morning and there she was given IV fluids. She was alright and returned home.
But since one day she complaints of anuria,SOB and abdominal distension.
Past history:
Known case of hypertension since 8 years
9 years ago she had a history of right lower limb swelling
Which was associated with fever.
She had similar complaints 9 months back for which she went to hospital and got treated.
Personal history:
Diet:vegetarian
Appetite:normal
Sleep:adequate
Bowel and bladder movements:
Addictions: drinks toddy occasionally (once in 2 months)
Daily routine:
She was an active 55 year old agricultural labourer who used to wake up at 4am in the morning and finishes off her household works by 9 am and goes to field after having her breakfast. She returns home by 6pm and and sleeps at 9pm. She eats rice and curry for breakfast, lunch and dinner everyday.
General examination:
Patient is conscious, coherent and cooperative
Pallor
No Icterus
No Cyanosis
No Clubbing
No Lymphadenopathy
Edema present
Systemic examination
CVS: s1 s2 present
No murmurs
RS: bilateral air entry present
Normal vesicular breath sounds heard
PER ABDOMEN : distended
CNS : patient is drowsy but arousable
INVESTIGATIONS
23/1/23
RBS:124mg/dl
LFT
TOTAL BILIRUBIN:1.72
DIRECT BILIRUBIN:0.38
SGOT:88
SGPT:39
ALP:213
TOTAL PROTEINS:3.8
ALBUMIN:2.0
A/G:0.82
Phosphorus:6.2
Calcium:8.6
Serum creatinine:3.8
Serum uric acid:8.4
Serum magnesium:2.0
Sodium:139
Potassium:4.1
Chloride:100
Calcium ionized:0.83
Chest x ray (23/1/23)
?septic encephalopathy ?uremic encephalopathy
Septic shock with MODS(AKI,ALI) with multifocal atrial tachycardia (resolving) with right lower limb cellulitis with ? Pulmonary embolism with grade 2 bedsore s/p 4 sessions of hemodialysis done
Treatment:
IV fluids NS and RL @ 50ml/hr
Nebulisation with duolin 8th hrly, budecort and mucomist 12th hrly
RT feeds 50ml free water 2nd hrly
50ml milk with protein powder 4th hrly
Inj meropenem 500mg IV/BD (day2)
Inj pan 40 mg OD
Inj clindamycin 600mg IV TID (day7)
Inj lasix 40mg IV /BD
Inj neomol 1gm iv sos(if temp >101F)
Inj heparin 5000IU iv BD
Tab metxl 12.5mg RT/OD
Tab shelcal po od
Tab pcm 650 mg po bd
Position change 4th hrly
Oint thrombophobe gel for LA/BD
Right lower limb elevation and dressing
B/l bed sore dressing
Investigations on
24/1/23 25/1/23 26/1/23 27/1/23
Hb:10.9 10.2 10.2 9.5
TLC:20,200 13,000 10,300 8,300
RBC:4.30 3.79 3.81 3.59
PLT:1.78 1.4 1.5 1.0
Urea:110 146 130 164
Creat:3.7 4.8 3.6 4.4
Sodium:145 126 136 134
Potassium:3.9 3.2 3.4 3.2
Chloride:103 92 101 102
Investigations. 28/1/23. 29/1/23. 30/1/23
Hb 8.6 8.3
TLC 8,100 10,200
RBC 3.23 3.1
PLT 88,000 1.1
UREA 78
CREAT 3.2
SODIUM 134
POTASSIUM 3.7
CHLORIDE. 105
Investigations. 31/1/23. 1/2/23. 2/2/23. 3/2/23
Hb 7.9 6.3 5.7 6.5
Tlc 17,600 17,100 12,600 11,800
Rbc 3.0 2.3 2.1 2.33
Plt 1.4 1.54 1.73 1.80
Urea 91 104 117 111
Creatinine 3.9 4.6 5.1 5.3
Sodium 133 136 135 135
Potassium 4.2 4.5 4.2 3.7
Chloride 1.03. 104 101. 99
Investigations. 4/2/23. 5/2/23
Hb 6.3 7.6
Tlc 15,500 13,400
Rbc 2.31
Plt 2.16 1.9
Urea 127 69
Creatinine 6.0 4.0
Sodium 141 138
Potassium 3.9 3.3
Chloride 98 98
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