68 years FEMALE WITH SEPTIC SHOCK SECONDARY TO CELLULITIS, ATRIAL FIBRILLATION WITH FVR, HYPERTENSION


68 years FEMALE came with complaints of pain and swelling of left lower limbs since 7 days
FEVER since 4days
VOMITINGS since yesterday

HOPI :
patient with apparently alright before 7 days, suddenly she got injury due to thorn prick on anterior aspect of left leg followed by swelling of left leg and foot which is gradually increasing
Fever is high grade assocated with chills and rigors continuous 
VOMITINGS sudden in onset since yesterday non bilious and non projectile not associated with pain abdomen , no h/o loose stools

PAST HISTORY : 
k/c/o. Hypertension since 3 yrs (medicine not known) 
k/c/o.CVA since 2005 with left sided hemeperasis resolved after 1 year
Not a konwn case of DM/TB/ASTHAMA/EPILEPSY/CAD

PERSONAL HISTORY :
Diet - mixed
Appetite - decreased
Bladder - Normal
Bowel - Regular
Alcohol - occasional
Smoking - No h/o smoking

DRUG HISTORY : 
No known drug allergies

FAMILY HISTORY : 
No DM/HTN/TB/ASTHAMA/EPILEPSY/CAD

GENERAL PHYSICAL EXAMINATION :
Moderately built and moderately nourished
Pallor - present
No icterus
No cynosis
No clubbing
No lyphedenopathy
B/L pedal edema present with wounds seen over anterior aspect of left leg and medial and lateral aspect of left ankle joint
Before DRESSING 👆
After DRESSING 👆

VITALS :
patient is Concious, coherant, cooperative
Temp -100 f
Pulse : 110 bpm, irregular
BP - 90/60mm of hg
CVS - s1, s2 present, no murmurs
RS - B/L AE present, NVBS present
PA - soft, non tender, no organo megaly
CNS - nfnd

LAB INVESTIGATIONS :

HEMOGRAM :
Hb - 8.8
Tlc - 21,000
Platelets - 1,3 L/cu.mm
CUE :
Ketone bodies -1+
Pus cells - 2 to 4

 RBS 112 mg/dl

RFT : 
Urea - 132
Creatinine - 3.3
Na - 137
K+ - 4.7
Cl - 102

LFT :
Total bilurubin -1.15
Direct bilurubin - 0.25
Sgot - 32
Sgpt - 30
Alp - 117
Albumin - 2.6

LIPID PROFILE :
Serum cholesterol -147
Triglycerides -209
Hdl -25
Ldl -57.6
Vldl - 41.8
ECG ON 14/03/2024 , 1.15PM👇


ECG ON 14/03/2024  3.45PM 👇

ON EXAMINATION : 
patient is Concious, coherant, cooperative
JVP -Raised
APEX PULSE DEFICIT - 12
Temp -100 f
Pulse : 110 bpm, irregular
BP - 90/60mm of hg
CVS - s1, s2 present, no murmurs
RS - B/L AE present, NVBS present
PA - soft, non tender, no organo megaly
CNS - nfnd

PROVISIONAL DIAGNOSIS :
SEPTIC SHOCK SECONDARY TO CELLULITIS
ATRIAL FIBRILLATION with FVR
K/c/o CVA with LEFT HEMI PERASIS 

TREATMENT :
IVF - NS @100ml / hr
inj. Met. Xl 1cc.iv.sos
inj. Norad 2amp. in 46ml NS @5ml/hr (to maintain MAP 65/min)
inj. Amiodarone 300 mg. iv. Bolus
Tab. Met. Xl 12.5mg po. BD
inj. Heparin 5000 IU . iv. QID
inj. Metrogyl 400mg iv. Tid
inj. Meropenam 500mg iv .BD
inj. Amiodarone 2amp.in 44ml NS @ 8.2ml /hr
Strict I/O.charting
Monitor vitals 

ECG ON 15/03/2024 6.15am
ON EXAMINATION ON 15/03/2024 , 8am
patient is Concious, coherant, cooperative
JVP -Raised
APEX PULSE DEFICIT - 10
Temp -98.9f
Pulse : 130 bpm, irregular
BP - 110/70mm of hg
RR - 24 cpm
SPO2 - 98%@RA
CVS - s1, s2 present, no murmurs
RS - B/L AE present, b/l crepts +
PA - soft, non tender, no organo megaly
CNS - nfnd

PROVISIONAL DIAGNOSIS :
SEPTIC SHOCK SECONDARY TO CELLULITIS left lower limb , SEPSIS WITH MODS 
ATRIAL FIBRILLATION (paraxysmal)with FVR
K/c/o CVA with LEFT HEMI PERASIS 13yrs ago
K/c/o Hypertension since 3years

TREATMENT :
IVF - NS @100ml / hr
inj. Noradrenaline 0.16mg/ml. in 6ml/hr   (to maintain MAP 65 mm of hg) 
inj. Amiodarone 6mg/ml @8.2ml/hr
Tab. Met. Xl 12.5mg po. BD
inj. Heparin 5000 IU . iv. TID
inj. Metrogyl 400mg iv. Tid
inj. Meropenam 500mg iv .BD
inj. Amiodarone 2amp.in 44ml NS @ 8.2ml /hr
inj. Pantop 40mg iv OD
Tab. Chymoral forte po. BD
Tab. Mvt po. OD
inj. Lasix 20mg iv TID
Syp. Lactulose 15 ml BD
Strict I/O.charting
GRBS monitoring
Monitor vital
ECG ON 16/03/2024 7.10pm
ON EXAMINATION ON 16/03/2024 8am

patient is Concious, coherant, cooperative
JVP -Raised
APEX PULSE DEFICIT - 12
Temp -98.4 f
Pulse : 144 bpm, irregular
BP - 130/80mm of hg
RR - 24 cpm
SPO2 - 98%@RA
CVS - s1, s2 present, no murmurs
RS - B/L AE present, b/l crepts +
PA - soft, non tender, no organo megaly
CNS - nfnd
I /O. 2550 /1450
GRBS : 87 mg/dl

PROVISIONAL DIAGNOSIS :
SEPTIC SHOCK (resolved) SECONDARY TO CELLULITIS left lower limb , 
ALTERED SENSORIUM secondary to (septic/uraemic) ENCEPHALOPATHY
AKI (pre renal) on CKD 
ATRIAL FIBRILLATION (paraxysmal)with FVR
K/c/o CVA with LEFT HEMI PERASIS 13yrs ago
K/c/o Hypertension since 3years
S / P 1.SESSION OF HEMODIALYSIS on 16/03/2024

TREATMENT :
IVF - NS ,RL, DNS @100ml / hr
inj. Noradrenaline 0.16mg/ml. in 6ml/hr   (to maintain MAP 65 mm of hg) 
Tab. Cardarone 200mg . po. BD
Tab. Met. Xl 25 mg po. BD
inj. Heparin 5000 IU . iv. TID
inj. Metrogyl 400mg iv. Tid (STOP) 
inj. Meropenam 500mg iv .BD
inj. Amiodarone 2amp.in 44ml NS @ 8.2ml /hr
inj. Pantop 40mg iv OD
Tab. Chymoral forte po. BD
Tab. Mvt po. OD
inj. Lasix 40mg iv TID
Syp. Lactulose 15 ml BD
Strict I/O.charting
GRBS monitoring
Monitor vital

ECG ON 17/03/2024 7am

ON EXAMINATION ON 17/03/2024 8am

patient is Concious, coherant, cooperative
JVP -Raised
APEX PULSE DEFICIT - 12
Temp -98.6 f
Pulse : 90 bpm, irregular
BP - 130/80mm of hg
RR - 24 cpm
SPO2 - 98%@RA
CVS - s1, s2 present, no murmurs
RS - B/L AE present, b/l crepts +
PA - soft, non tender, no organo megaly
CNS - nfnd
I /O. 2550 /1450
GRBS : 87 mg/dl

PROVISIONAL DIAGNOSIS :
SEPTIC SHOCK (resolved) SECONDARY TO CELLULITIS left lower limb , 
ALTERED SENSORIUM secondary to (septic/uraemic) ENCEPHALOPATHY
AKI (pre renal) on CKD 
ATRIAL FIBRILLATION (paraxysmal)with FVR
K/c/o CVA with LEFT HEMI PERASIS 13yrs ago
K/c/o Hypertension since 3years
S / P 1.SESSION OF HEMODIALYSIS on 16/03/2024

TREATMENT :
IVF - NS ,RL, DNS @100ml / hr
inj. Noradrenaline 0.16mg/ml. in 6ml/hr   (to maintain MAP 65 mm of hg) 
Tab. Cardarone 200mg . po. BD
Tab. Met. Xl 25 mg po. BD
inj. Heparin 5000 IU . iv. TID
inj. Clindamycin 600mg iv. TID
inj. Meropenam 500mg iv .BD
inj. Pantop 40mg iv OD
Tab. Chymoral forte po. BD
Tab. Mvt po. OD
inj. Lasix 40mg iv TID
Syp. Lactulose 15 ml BD
Strict I/O.charting
GRBS monitoring
Monitor vital

ECG ON 18/03/2024 11.40am
ON EXAMINATION ON 19/03/2024 8am

patient is Concious, coherant, cooperative
JVP -Raised
APEX PULSE DEFICIT - 12
Temp -98.4 f
Pulse : 90 bpm, irregular
BP - 180/100mm of hg
RR - 22 cpm
SPO2 - 98%@RA
CVS - s1, s2 present, no murmurs
RS - B/L AE present, b/l crepts +in left ISA, IAA
PA - soft, non tender, no organo megaly
CNS - nfnd
I /O. 3300 /2100
GRBS : 100 mg/dl

PROVISIONAL DIAGNOSIS :
SEPTIC SHOCK (resolved) SECONDARY TO CELLULITIS left lower limb (resolving) 
ALTERED SENSORIUM secondary to (septic/uraemic) ENCEPHALOPATHY
AKI (pre renal) on CKD 
ATRIAL FIBRILLATION (paraxysmal)with FVR
K/c/o CVA with LEFT HEMI PERASIS 13yrs ago
K/c/o Hypertension since 3years
S / P 2.SESSION OF HEMODIALYSIS on 16/03/2024 , 18/03/2024

TREATMENT :
IVF - NS ,RL,  @ 75 ml / hr
inj. Noradrenaline 0.16mg/ml. in 6ml/hr   (to maintain MAP 65 mm of hg) 
Tab. Cardarone 200mg . po. BD
Tab. Met. Xl 25 mg po. BD
inj. Heparin 5000 IU . iv. TID
inj. Clindamycin 600mg iv. TID
inj. Meropenam 500mg iv .BD
inj. Pantop 40mg iv OD
inj. iron sucrose 200mg in 100ml NS iv. OD
Tab. Pcm 650 mg BD
Tab. Chymoral forte po. BD
Tab. Nodosis 500mg po. BD
Tab. Acitrom 2.5mg OD
Tab. Febuxostat 40mg . Po. OD
Tab. Mvt po. OD
inj. Lasix 40mg iv TID
Syp. Lactulose 15 ml BD
Strict I/O.charting
GRBS monitoring
Monitor vital

ECG ON 19/03/2024 6am
ON EXAMINATION ON 19/03/2024 8am

patient is Concious, coherant, cooperative
JVP -Raised
APEX PULSE DEFICIT - 12
Temp -99.1 f
Pulse : 92 bpm, irregular
BP - 140/90mm of hg
RR - 20 cpm
SPO2 - 98%@RA
CVS - s1, s2 present, no murmurs
RS - B/L AE present, b/l crepts +in left ISA, IAA
PA - soft, non tender, no organo megaly
CNS - nfnd
I /O. 2300 /1400
GRBS : 126 mg/dl

 DIAGNOSIS :

SEPTIC SHOCK (resolved) SECONDARY TO CELLULITIS left lower limb (resolving) 
ALTERED SENSORIUM secondary to (septic/uraemic) ENCEPHALOPATHY
AKI (pre renal) on CKD 
ANAEMIA secondary to CKD
ATRIAL FIBRILLATION (paraxysmal)with FVR
K/c/o CVA with LEFT HEMI PERASIS 13yrs ago
K/c/o Hypertension since 3years
S / P 2.SESSION OF HEMODIALYSIS on 16/03/2024 , 18/03/2024


TREATMENT :
IVF - NS ,RL,  @ 75 ml / hr
inj. Noradrenaline 0.16mg/ml. in 6ml/hr   (to maintain MAP 65 mm of hg) 
Tab. Cardarone 200mg . po. BD
Tab. Met. Xl 25 mg po. BD
inj. Heparin 5000 IU . iv. TID
inj. Clindamycin 600mg iv. TID
inj. Meropenam 500mg iv .BD
inj. Pantop 40mg iv OD
inj. iron sucrose 200mg in 100ml NS iv. OD
inj. Erythropoeitin 4000 IU S/C OD
Tab. Pcm 650 mg BD
Tab. Chymoral forte po. BD
Tab. Nodosis 500mg po. BD
Tab. Acitrom 2.5mg OD
Tab. Febuxostat 40mg . Po. OD
Tab. Mvt po. OD
inj. Lasix 40mg iv TID
inj. Kcl 2amp in 500ml NS IV stat 
Syp. Potklor 15 ml TID
Syp. Lactulose 15 ml BD
Strict I/O.charting
GRBS monitoring
Monitor vital

ECG ON 20/03/2024 6.20 am
ON EXAMINATION ON 20/03/2024 8am

patient is Concious, coherant, cooperative
JVP -Raised
APEX PULSE DEFICIT - 12
Temp -101 f
Pulse :74 bpm, irregular
BP - 150/90mm of hg
RR - 20 cpm
SPO2 - 98%@RA
CVS - s1, s2 present, no murmurs
RS - B/L AE present, b/l crepts +in left ISA, IAA
PA - soft, non tender, no organo megaly
CNS - nfnd
I /O. 
GRBS :  mg/dl

DIAGNOSIS :

SEPTIC SHOCK (resolved) SECONDARY TO CELLULITIS left lower limb (resolving) 
ALTERED SENSORIUM secondary to (septic/uraemic) ENCEPHALOPATHY
AKI (pre renal) on CKD 
ANAEMIA secondary to CKD
ATRIAL FIBRILLATION (paraxysmal)with FVR(resolved) 
K/c/o CVA with LEFT HEMI PERASIS 13yrs ago
K/c/o Hypertension since 3years
S / P 3.SESSION OF HEMODIALYSIS on 16/03/2024 , 18/03/2024 , 20/03/2024

TREATMENT :
IVF - NS ,RL,  @ 75 ml / hr
inj. Noradrenaline 0.16mg/ml. in 6ml/hr   (to maintain MAP 65 mm of hg) 
Tab. Cardarone 200mg . po. BD
Tab. Met. Xl 25 mg po. BD
inj. Heparin 5000 IU . iv. TID
inj. Clindamycin 600mg iv. TID
inj. Meropenam 500mg iv .BD
inj. Pantop 40mg iv OD
inj. iron sucrose 200mg in 100ml NS iv. OD
inj. Erythropoeitin 4000 IU S/C OD
Tab. Pcm 650 mg BD
Tab. Chymoral forte po. BD
Tab. Nodosis 500mg po. BD
Tab. Acitrom 2.5mg OD
Tab. Febuxostat 40mg . Po. OD
Tab. Mvt po. OD
inj. Lasix 40mg iv TID
inj. Kcl 2amp in 500ml NS IV stat 
Syp. Potklor 15 ml TID
Syp. Lactulose 15 ml BD
Strict I/O.charting
GRBS monitoring
Monitor vital
PATIENT IS DISCHARGED AND ADMITTED IN Dept. Of GENERAL SURGERY for further active surgical intervention of CELLULITIS LEFT LOWER LIMB on 21.03.3024 . 













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