60 F CAME WITH FEVER AND LOOSE STOOLS

Unit posting (Intern 2017)

AMC Bed no-2 

GM II 

Dr Nikitha

Dr Pavan

Dr Lohith

Dr Sneha

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Patient complaints of fever since 3 days, SOB since 2 days and loose stools today. 

HISTORY OF PRESENTING ILLNESS- 

Patient was apparently asymptomatic 3-4 days ago, then she developed low grade fever, intermittent nature, relieved on iv medication, associated with generalized weakness associated with SOB since 2 days (Grade 4 of MMRC at time of presentation) 

- No h/o palpitations, chest pain, cold, cough, burning micturition, and rashes. 

- Has h/o abdominal bloating and discomfort and c/o loose stools of low volume, not associated with pain abdomen.

- loose watery stools 3-4 episodes today. 

HER DAILY ROUTINE- 

- She’s a coolie by occupation, works 8-5 daily, consumes rice in all three meals and often complained of body pains due to her field of work so used to consume non- prescribed pain medications (unknown). 

- She had complained of fever 3 days prior to her visit to our hospital, for which she had gone to a RMP doctor who prescribed her medication for her fever along with IV fluids. Her symptoms were relieved then. 

- a day before her visit to our hospital she had complained of abdominal pain for which she visited a local hospital who referred her to us. 

PAST HISTORY- 

- no h/o similar complaints in the past 

- no h/o DM, HTN, Asthma, Epilepsy, Tuberculosis, CVA, CAD

GENERAL PHYSICAL EXAMINATION- 

• well built and nourished 
• No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema
• Vitals

Pulse rate- 120 beats per minute

Respiratory rate- 36 cycles per minute 

Temperature- Afebrile 

Blood pressure- 90/60mmHg

GRBS- 96mg/dl

SYSTEMIC EXAMINATION- 

Abdominal examination- 

- Soft, non tender, 

- no organomegaly 

- Bowel sounds present

Cardiovascular system examination 

•S1 and S2 heard , no added thrills and murmurs heard.

Respiratory system examination 

- BLAE present 

- NVBS 

- On Auscultation- crepitations heard on B/L infra axillary region, and Infra scapular region, Right more than left side. 

Central nervous system examination- 

• Conscious 
• Normal speech 
• Cranial nerves intact
• Sensory and motor system- normal 
• Neck stiffness- absent
• Reflexes- normal

DIAGNOSIS- 

- Septic Shock with Community Acquired Pneumonia with Acute Kidney Injury

INVESTIGATIONS- 

14/06/2023

ABG at 9:30 am 

ABG at 8:30 pm 

USG FINDINGS (IMPRESSION) -Minimal Ascites noted. 

Urine culture and sensitivity- no significant growth. 

Blood culture- Gram Negative organism isolated 

15/06/2023

Bedside chest X-ray 

- E/O radio-opacities notes in B/L lung fields, predominantly noted in the lower lobes 

- Right hilar enlargement noted 

- heart and trachea are central 

- the diaphragm show smooth outline 

Impression- Consolidatory changes noted in B/L lung fields. 

Haemogram- 

Serum Electrolytes- 

ABG at 8am- 

ABG at 7pm- 

pH- 7.385

pCO2- 21.6  mmHg 

pO2- 53.5 mmHg

cHCO3- 15.9 mmol/L 

Sr creatinine- 

Sr Urea- 

 

16/06/2023- 

ABG done at 4am- 

pH- 7.340

pCO2- 21.7 mmHg

pO2- 63.3 mmHg

cHCO3- 13.5 mmol/L

Hemogram- 

Serum electrolytes with urea and creatinine- 

Blood lactate- 

Blood culture- E.Coli isolated (sensitive to Cotrimoxazole, Piperacillin/Tazobactam, Meropenam.) 

2D ECHO- 

- mild to moderate MR, moderate AR, mild TR

- no RWMA, No AS/MS, sclerotic AV

- Good LV systolic function 

- diastolic dysfunction, no PE 

17/6/23- 

- Serum Electrolytes with urea and creatinine 

- ABG 

- Haemogram 

- chest X-ray sitting position 

Intubation done on 17/6/23 at 3:30pm due to oxygen desaturation. 

Post intubation ABG- 

pH- 7.210

pCO2- 30.9 mmHg

pO2- 42.1 mmHg

HCO3- 12.9 mmol/L

Post intubation chest X-ray 

Fever chart- 

TREATMENT- 

 

1. IV Fluids NS @ 100ml/hr

2. Inj MONOCEF 1gm IV BD 

3. Inj PAN 40mg IV OD 

4. Inj 25 D if GRBS- 60mg/do

5. Temperature charting every 4th hourly 

6. Monitor vitals 

7. Inj.Piptaz 1gm IV BD / day 3

On 17/6/23- 

1. IV FLUIDS - NS, RL @100ML/HR

2. (DAY 4) INJ PIPTAZ 2.25GM IV TID

3. (DAY 3) TAB AZITHROMYCIN 500MG PO OD

4. INJ PANTOP 40MG IV OD

5. INJ 25D IV STAT IF GRBS <60MG/DL 

6.BP,PR, SPO2, RR CHARTING HOURLY

7. TEMP MONITORING 4TH HOURLY

8.STRICT I/O CHARTING

9. ORS SATCHET IN 1LITRE WATER AFTER EVERY LOOSE STOOL EPISODE

Patient expired on 17/06/2023 at 6:21 pm- 

Due to sudden bradycardia with no central and peripheral pulses, CPR was initiated according to ACLS guidelines and was continued for 30 minutes despite which patient could not be resuscitated and was declared dead at 6:21pm on 17/6/23 with ECG showing no electrical activity. 

Immediate cause of death- Type 1 respiratory failure with refractory metabolic acidosis 

Antecedent cause of death- Acute Respiratory Distress Syndrome with Septic Shock with MODS with ?DIC