A CASE OF SEPSIS PRESENTED IN SUMMER 2022
NOTE:
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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 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 clothes)
➤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
INVESTIGATIONS :
1) TEMPERATURE CHART
2) USG
3) ECG
TREATMENT
Day-1
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
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
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
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
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
10) INJ.NEOMOL 15ML IV SOS
