Case 35 84 male Lt below knee amputation with fever of 10 days

Diagnosis

SEPSIS WITH MODS SECONDARY TO INFECTED LEFT LOWER LIMB STUMP[RESOLVING]

RENAL AKI ON CKD STAGE 5

TYPE II DM SINCE 7 YRS

S/P 3 SESSIONS OF HEMO DIALYSIS

S/P 2 UNITS PRBC TRANSFUSION

S/P BELOW KNEE AMPUTATION OF LEFT LOWER LIMB

Case History and Clinical Findings

CHIEF COMPLAINTS:

FOLLOW UP CASE OF LEFT BELOW KNEE AMPUTATION

C/O FEVER SINCE 10 DAY

HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS AGO THEN HE DEVELOPED FEVER

WHICH WAS SUDDEN IN ONSET ASSOCIATED WITH CHILLS AND RIGOR. NO AGGRAVATING

FACTORS. NOT RELIEVING ON MEDICATIONS

NO H/O VOMITING

NO H/O CONSTIPATION, LOOSE STOOLS

PAST HISTORY:

K/C/O DM SINCE 6 YEARS ON INSULIN (HAI)

H/O AMPUTATION OF LEFT LOWER LIMB BELOW KNEE DONE 2 MONTHS AGO

N/K/C/O HTN, EPILEPSY, THYROID DISORDER, CVA, CAD, ASTHMA

A 84 YR OLD MALE KNOWN DIABETIC WITH S/P LEFT BELOW KNEE AMPUTATION 2 MONTHS

BACK PRESENTED TO GENERAL SURGERY OPD WITH C/O FEVER SINCE 10 DAYS AND

BREATHLESSNESS SINCE 7 DAYS AND DECREASED URINE OUTPUT.ON FURTHER

EVALUATION HE WAS FOUND TO HAVE SEPSIS WITH MODS AND WAS TRANSFERRED TO

GENERAL MEDICINE FOR FURTHER MANAGEMENT. I/V/O RAISED RENAL

PARAMETERS[UREA-106,CREATININE-4.6] WITH METABOLIC ACIDOSIS, PATIENT WAS

TAKEN UP FOR HEMODIALYSIS AND APPROPRIATE ANTIBIOTICS WERE INITIATED AND

OTHER SYMPTOMATIC TREATMENT WAS GIVEN. REGULAR DRESSINGS WERE DONE FOR

THE STUMP. PATIENT IMPROVED SYMPTOMATICALLY WITH REDUCED BREATHLESSNESS

IMPROVED URINE OUTPUT AND NO FEVER SPIKES AND HE IS BEING DISCHARGED IN

HEMODYNMAICALLY STABLE CONDITION

Investigation

COMPLETE BLOOD PICTURE (CBP) 26-08-2024

HAEMOGLOBIN 8.2 gm/dl

TOTAL COUNT 30000 cells/cumm

NEUTROPHILS 93 %

LYMPHOCYTES 03 %

EOSINOPHILS 01 %

MONOCYTES 03 %

BASOPHILS 00 %

PLATELET COUNT 3.94

SMEAR Normocytic normochromic anemia with neutrophilic leucocytosis

COMPLETE URINE EXAMINATION (CUE) 26-08-2024 12:55:PM

COLOUR Reddish

APPEARANCE Cloudy

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN +

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 8-10

EPITHELIAL CELLS 1-2

RED BLOOD CELLS plenty

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

Anti HCV Antibodies - RAPID 26-08-2024 Non Reactive

HBsAg-RAPID 26-08-2024 Negative

RFT 26-08-2024

UREA 94 mg/dl

CREATININE 4.0 mg/dl

URIC ACID 4.4 mmol/L

CALCIUM 8.7 mg/dl

PHOSPHOROUS 4.0 mg/dl

SODIUM 135 mmol/L

POTASSIUM 3.2 mmol/L

CHLORIDE 102 mmol/L

COMPLETE BLOOD PICTURE (CBP) 26-08-2024

HAEMOGLOBIN 8.6 gm/dl

TOTAL COUNT 34600 cells/cumm

NEUTROPHILS 88 %

LYMPHOCYTES 08 %

EOSINOPHILS 00 %

MONOCYTES 04 %

BASOPHILS 00 %

PLATELET COUNT 4.07

SMEAR Normocytic normochromic anemia with neutrophilic leucocytosis

COMPLETE URINE EXAMINATION (CUE) 26-08-2024

COLOUR PALE

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

Alb +

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 3-4

EPITHELIAL CELLS 2-3

RED BLOOD CELLS 4-5

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

POST LUNCH BLOOD SUGAR 26-08-2024 101 mg/dlg/dl

RFT 26-08-2024

UREA 92 mg/dl

CREATININE 4.0 mg/dl

URIC ACID 4.5 mmol/L

CALCIUM 7.9 mg/dL

PHOSPHOROUS 4.6 mg/dl

SODIUM 133 mmol/L

POTASSIUM 3.2 mmol/L.

CHLORIDE 101 mmol/L

LIVER FUNCTION TEST (LFT) 26-08-2024

Total Bilurubin 1.06 mg/dl

Direct Bilurubin 0.24 mg/dl

SGOT(AST) 13 IU/L

SGPT(ALT) 10 IU/L

ALKALINE PHOSPHATASE 290 IU/L

TOTAL PROTEINS 5.2 gm/dl

ALBUMIN 2.12 gm/dl

A/G RATIO 0.69

ABG 27-08-2024 03:27:PM

PH 7.26

PCO2 11.5

PO2 42.7

HCO3 5.0

St.HCO3 8.2

BEB -21.3

BEecf -21.4

TCO2 11.3

O2 Sat 70.1

RFT 2-09-2024

UREA 115 mg/dl

CREATININE 5.6 mg/dl

URIC ACID 3 mmol/L

CALCIUM 8.9mg/dl 1

PHOSPHOROUS 3.7 mg/dl

SODIUM 142 mmol/L

POTASSIUM 3.6 mmol/L.

CHLORIDE 106mmol/L

COMPLETE BLOOD PICTURE (CBP) 1-09-2024

HAEMOGLOBIN 7.5 gm/dl

TOTAL COUNT 15200 cells/cumm

PLATELET COUNT 3.06

RBC - 2.54

SMEAR Normocytic normochromic anemia with neutrophilic leucocytosis

COMPLETE BLOOD PICTURE (CBP) 4-09-2024

HAEMOGLOBIN 8.9gm/dl

TOTAL COUNT 13600cells/cumm

PLATELET COUNT 2.36

RBC -3.06

SMEAR Normocytic normochromic anemia with neutrophilic leucocytosis

ULTRASOUND ABDOMEN

CLINICAL FINDINGS

E/O MULTIPLE RENAL CYSTS IN B/L KIDNEYS

IMPRESSION

B/L GRADE-1 RPD CHANGES WITH RENSL CYSTS

MINIMAL B/L PLEURAL EFFUSION

2D ECHO

NO RWMA, PARADOXICAL IVC

MILD MR+_[MR JET AREA[2.82 CM2]

TRIVIAL AR+, MILD TR+ WITH PAH

MAC+, SCLEROTIC AV, NO AS/MS

EF=55%, RVSP=32+10=42 MM HG

GOOD LV SYSTOLIC FUNCTION

GRADE-1 DIASTOLIC DYSFUNCTION +

IVC SIZE[1.12CMS] COLLAPSING

IAS-INTACT/ ANEURYSM

MINIMAL PE+, NO LV CLOT

Treatment Given(Enter only Generic Name)

IVF NS @ 30 ML /HR

INJ. MEROPENEM 500MG IV OD

INJ. AMIKACIN IGM IV OD EVERY 3RD DAY[2 DOSES GIVEN ON 31/8/24, 3/8/24

INJ. PAN 40 MG IV OD

INJ. PIPTAZ 2.25 GM, IV/TD

INJ. HAI SC TID ACCORDING TO GRBS

INJ. NEOMOL 1 GM IV SOS IF TEMP. >101.5F

INJ. LASIX 20MG IV TID

TAB. ECOSPRIN AV PO HS

TAB. PCM 650 MG PO TID

TAB. VIT-C PO OD

TAB. NODOSIS 500 MG PO BD

TA. SHELCAL X T PO OD

TAB. KUFFDRYL-O PO OD

TAB. PULMOCLEAR PO BD

NEB WITH IPRAVENTI 8TH HOURLY AND BUDECORT 12TH HRLY

INJ. EPO 6000 IU SC WEEKLY ONCE -GIVE TODAY

2-3 EGG WHITES/DAY

PROTEIN RICH DIET

REGUALR DRESSING OF LEFT LOWER LIMB

STRICT I/O CHARTING

GRBS 7 PROFILE

MONITER VITALS AND INFORM SOS

Advice at Discharge

T. AUGUMENTIN 625MG PO/BD FOR 5 DAYS

INJ. HUMAN ACTRAPID INSULIN S/C 4-4-4

TAB. LASIX 40 MG PO/TID TO CONTINUE

TAB. NODOSIS 500 MG PO/BD

TAB. SHELCAL-CT PO/OD

TAB. ECOSPRIN-AV 75/10 PO/HS

TAB. PULMOCLEAR PO/BD FOR 5 DAYS

TAB. PCM 650 MG PO/SOS

TAB.PAN 40 MG PO/OD

TAB. METROGYL 400MG FOR 3 DAYS

2 EGG WHITES / DAY

HIGH PROTEIN DIET

REGULAR DRESSINGS OF LEFT LOWER LIMB STUMP

Followup in january 2025

Stump healed

FBS 156 mg/dl

PLBS 234 mg/dl

Hba1c 6.8

Pt is non adherent to diabetic diet

POTASSIUM 2.7 mmol/L.

CHLORIDE 105mmol/L

RFT 4-09-2024

UREA 108mg/dl

CREATININE 4.0 mg/dl

URIC ACID 5.2 mmol/L

CALCIUM 7.9mg/dl 1

PHOSPHOROUS 3.8 mg/dl

SODIUM 137 mmol/L