A CASE OF SEPSIS PRESENTED IN SUMMER 2022

                                                                     NOTE:

  • The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed 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-log also reflects my patient's centered 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 providing treatment best to our skills and wisdom

A 38 years old man skilled worker by occupation presented in the casualty with complaints of  fever and headache.

CHIEF COMPLAINTs

➤ Fever for last 5 days 

➤Headache for last 5 days

➤Loss of appetite for last 5 days
    
➤Nausea for last 5 days



HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 5years back.  then he was in stress as his brother was having some serious health issues following to which he developed low grade fever and neck pain. then he was diagnosed with hypertension. 
For the last one week patient is having low grade fever associated with chill , headache and neck pain .
No joint pains and  no blurring of vision .Fever was not associated with rashes.

HISTORY OF PAST ILLNESS 

➤Not a known case of  diabetes ,bronchial asthma ,epilepsy, tuberculosis

➤k/c/o hypertension for 5 years

DRUG HISTORY

➤Tab Metoprolol 50 mg OD for HTN for last 5 years

➤Telmisartan 40mg

➤Chlorthalidone 12.5mg

PERSONAL HISTORY

➤ Occupation : Skilled worker(coloring cloths)

➤Patient is married

➤Patient takes mixed diet but has a normal appetite.

➤Bowel  movement is normal and and bladder movement is abnormal.

➤No addiction

➤No allergy

FAMILY HISTORY 

➤No significant family history.

GENERAL EXAMINATION 

➤Pallor :Not seen

➤Icterus :  Not seen

➤Cyanosis :  Not seen

➤Clubbing :  Not seen

➤Lymphadenopathy :  Not seen

➤Edema : Not seen

VITALS

➤Temperature : 98.3℉

➤PR : 102 beats per minute

➤BP : 130/90 mm of Hg

➤RR : 20 cycles per minute

➤SpO2 : 100% in room air

➤Blood Sugar (random) : 130mg/dl

SYSTEMIC EXAMINATION


CARDIOVASCULAR SYSTEM EXAMINATION

➤s1 and s2 heard

➤Thrills absent.,

➤No cardiac  murmurs

 RESPIRATORY SYSTEM

➤Normal vesicular breath sounds heard.

➤Bilateral air entry present

➤Trachea is in midline


ABDOMINAL EXAMINATION


INSPECTION

➤Shape - Scaphoid

➤Equal movements in all the quadrants.

➤No visible pulsation, dilated veins and localized swellings.

PALPATION

➤Tenderness present in epigastrium

➤Hepatomegaly

CENTRAL NERVOUS SYSTEM EXAMINATION

➤Conscious and coherent

PROVISIONAL DIAGNOSIS : SEPSIS WITH MODS SECONDARY TO BACTERIAL INFECTION

TEMPERATURE CHART



DAY 1

INVESTIGATIONS : 


USG



ECG


TREATMENT

1) IVF NS and  RL 100ML

2) INJ. PANTOP 40MG IV OD

3) TAB.PARACETAMOL 650 MG PO TID

4) INJ. OPTINEURON 1AMP IV OD

5) INJ.NEOMOL 15ML IV SOS

6) INJ. PIPTAZ 2.25MG IV TID

7) INJ. TRAMADOL 1AMP

DAY 2

TREATMENT

1) IVF NS and  RL 100ML

2) INJ. PANTOP 40MG IV OD

3) TAB.PARACETAMOL 650 MG PO TID

4) INJ. OPTINEURON 1AMP IV OD

5) INJ.NEOMOL 15ML IV SOS

6) INJ. PIPTAZ 2.25MG IV TID

7) INJ. TRAMADOL 1AMP


DAY 3

TREATMENT

1) IVF NS and  RL 100ML

2) INJ. PANTOP 40MG IV OD

3) TAB.PARACETAMOL 650 MG PO TID

4) INJ. OPTINEURON 1AMP IV OD

5) INJ.NEOMOL 15ML IV SOS

6) INJ. PIPTAZ 2.25MG IV TID

7) INJ. TRAMADOL 1AMP

8) INJ. ZOFER 4 MG IV SOS

9) TAB DOXY 

10) METOPROLOL


DAY 4

TREATMENT

1) IVF NS and  RL 100ML

2) INJ. PANTOP 40MG IV OD

3) TAB.PARACETAMOL 650 MG PO TID

4) INJ. OPTINEURON 1AMP IV OD

5) INJ. PIPTAZ 2.25MG IV TID

6) INJ. TRAMADOL 1AMP

7) INJ. LASIX

8) TAB DOXY 

9) METOPROLOL

DAY 5

TREATMENT

1) IVF NS and  RL 100ML

2) INJ. PANTOP 40MG IV OD

3) TAB.PARACETAMOL 650 MG PO TID

4) INJ. OPTINEURON 1AMP IV OD

5) INJ. PIPTAZ 2.25MG IV TID

6) INJ. TRAMADOL 1AMP

7) INJ. LASIX

8) TAB DOXY 

9) METOPROLOL

INJ.NEOMOL 15ML IV SOS

INJ. ZOFER 4 MG IV SOS





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