case of 45 years old man

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A 45 year old man presented to the casualty on 2/11/21 with the complaints of Fever since 4 days

Body pains since 4 days

Reduced urine output since 3 days

Vomiting yesterday

Hematuria since morning

Black tarry stools since morning

High grade fever, intermittent,not associated with chills and rigors .

2 episodes of non projectile, non bilious, blood tinged vomiting yesterday

He was taken to an outside hospital where in he received fluids and later the attenders decided to pay a visit to our hospital.

Hematuria since morning

1 episode of black tarry stool in the morning

He is a farmer by occupation and He works at the daily farm . His wife works as a farmer as well. His wife was previously admitted with us with ?meningitis. He has 2 children.

He is an alcoholic since the past 20 years with around 90 ml of whiskey everyday. His last intake of whiskey was 4 days. He smokes around 2 packs of beedi everyday since the past 20 years.

1 year back he presented to our hospital with the complaints of pain abdomen after which he underwent an abdominal surgery.

Since the past 4 years he has been experiencing high grade fever, intermittent with no diurnal variation associated with pain in his thigh muscles and arm.

Reduced urine output since morning

On presentation he is a thin built individual

Subconjunctival hemorrhage +

Icterus+

Pallor +

Clubbing +

Image of right eye showing icterus

Images of left eye showing sub conjuctival haemorrhage

Image showing yellowish discolouration of nails and clubbing

Bp was 60mmhg on palpation

PR - 115bpm

RR - 25 cpm

Spo2 - 92% on Room air

Afebrile

Lungs -

Inspiratory crepitations in Bilteral IAA,ISA

4/11/21 xray chest

7/11/21 chest xray

8/11/21 chest xray

11/11/21

Cvs - S1,S2+

Per Abdomen -

Soft

Nontender

HB - 8 ( outside 2 days back 11g/dl)

TLC - 8400

Plt - 15,000

Total Bilirubin - 11

Direct Bil - 7.05

Ast - 327

Alt - 187

Alp - 303

Albumin - 2.4

Serum creatinine - 2.5

Blood urea - 82

Dengue negative

Abg showing metabolic acidosis with PH 7.32

Hco3 - 9

Pco2 - 19

Po2 - 101 with oxygen on 6L of O2

Diagnosis -

Septic Shock with MODS secondary to ? Leptospirosis

Pyrexia with bicytopenia

Direct hyperbilirubinemia and prerenal AKI

3/11/21

In view of low platelet count of 14,000 sdp transfusion is planned.

After doing cross matching a screened unit of sdp is issued to the patient for transfusion after taking consent from the patient attenders.

Post transfusion the platelet count is improved to 35000.

4/11/21

S- patient is complaining of, productive cough with hemoptysis ,

chest pain - non radiating , burning type ,

Increasing on coughing and taking deep inspiration

O- icteric,pallor, subconjunctival hemorrhage

PR-112

BP- 110/80 mmhg on Noradrenaline -16 ml /hr

RR- 36/min

Spo2- 99% of

RS- BAE present ,crepts over left infraxillary ,infrascpular regions .

CvS- S1, S2 heard

P/ A soft

Urine output - increased

I/O - 3200/1300 ml

A- Septic shock secondary to leptospirosis ( Pre Renal AKI - resolving

Pyrexia with bicytopenia

Hypoxia + - secondary to ARDS?

P- Oxygen supplementation @14 litres/ min to maintain spo2 more than 95%

Iv fluids

Inj . ceftriaxone 1gm / IV/BD

Inj.doxy 100 mg / IV/BD

TEMP charting ,vitals monitoring

This case is intubated in view of respiratory failure..on 4/11/21

ABG shows

pO2:-41

FiO2:-60

Patient ET tube blocked with blood clot .

Even after mucomist,ambu and suction saturations weren't improving .

Removed and placed a new tube.

During which patient had Bradycardia ,hypoxia and absent central and peripheral pulses ,

3 cycles of CPR done , patient revived .

Post CPR vitals -

Pupils -

PR-112/ min ,regular

Bp-110/80 mmHg

RS - BAE + , bilateral diffuse crepetations +

CVS-s1 ,S2 heard

Spo2-100% with Fio2-80 %

ABG - severe acidosis mixed metabolic and respiratory -acidosis

Image showing chest xray post reintubation

5/11/21

2 units of FFP is transfused after doing crossmatching.Consent was obtained for transfusion from the patient attenders and transfusion done

Day 2 of mechanical ventilation .

Patient is becoming conscious intermittently ,with eye openings to painful stimuli and verbal commands .

Fever spikes present .

O- Pt onmechanical ventilation -AcMV - VC mode

With RR- 33/ min

Peep - 7

VT-400 ml

Fio2-21 %

icteric,pallor, subconjunctival hemorrhage

Pupils - normal size ,non reacting to light

Afebrile

PR-97/ min ,regular

BP- 120/80 mmhg

Spo2- 94% with fio2-21%

RS- BAE present ,bilateral crepts + infraxillary ,infrascpular regions .

CvS- S1, S2 heard

P/ A soft

Urine output - increased

A- MODS- weils syndrome

P-

Iv fluids

Inj . ceftriaxone 1gm / IV/BD

Inj.doxy 100 mg / IV/BD

TEMP charting ,vitals monitoring.

Weaning sedation .

Plan to - Shift to CPAP mode

7/11/21

Extubation done at 01:00pm on 7/11/21

Under all aseptic precations,with premedication inj.HYDROCORT 100MG IV STAT and nebulisation with BUDECORT and MUCOMIST , extubation was done. Procedure was uneventful and post extubation vitas are stable.

Bp :120/70mmhg

Pr :108bpm

Spo2 : 98% On 10L of O2

Cvs : s1 s2 heard

RS : BAE present

P/A :soft and nontender

GCS : E4V5M6

Day 1 after extubation

weils syndrome MODS

S- patient is having fever spikes , cough with sputum yellow coloured,non blood stained ,shortness of breath , generalized bodypains .

Yesterday night - patient had one episode of high grade fever with chills ,became tachypneic .

Connected to NIV - CPAP.

O- ABG with high flow oxygen showed Hypoxia ,hence

Patient was on CPAP PC mode overnight

With RR- 33/ min

Peep - 7

Fio2-50%

icteric,pallor, subconjunctival hemorrhage

Afebrile

PR-90/ min ,regular

BP- 130/90 mmhg

RR-37 / min

Spo2- 100% with fio2-80%

RS- BAE present ,bilateral crepts + infraxillary ,infrascpular regions .

CvS- S1,S2 heard

P/ A soft

A-

1-MODS- weils syndrome

2- ARDS?

P-

Iv fluids

Inj . ceftriaxone 1gm / IV/BD

Inj.doxy 100 mg / IV/BD

TEMP charting ,vitals monitoring.

In view of persistent fever spikes ,hypoxia , tachypnea,new radiological opacties -Emperical antibiotic coverage for VAP was started with levofloxacin and vancomycin .

8/11/21

weils syndrome MODS

S- patient is having fever spikes , cough with sputum yellow coloured,non blood stained ,shortness of breath , generalized bodypains .

Yesterday night - patient had one episode of high grade fever with chills ,became tachypneic .

Connected to NIV - CPAP.

O- ABG with high flow oxygen showed Hypoxia ,hence

Patient was on CPAP PC mode overnight

With RR- 33/ min

Peep - 7

Fio2-50%

icteric,pallor, subconjunctival hemorrhage

Afebrile

PR-90/ min ,regular

BP- 130/90 mmhg

RR-37 / min

Spo2- 100% with fio2-80%

RS- BAE present ,bilateral crepts + infraxillary ,infrascpular regions .

CvS- S1,S2 heard

P/ A soft

A-

1-MODS- weils syndrome

2- Ventilator Associated pneumonia ?

P-

Iv fluids

Inj . ceftriaxone 1gm / IV/BD

Inj.doxy 100 mg / IV/BD

TEMP charting ,vitals monitoring.

In view of persistent fever spikes ,hypoxia , tachypnea,new radiological opacties -Emperical antibiotic coverage for VAP was started with levofloxacin and vancomycin .

9/11/21

S- patient is having fever spikes , cough with sputum yellow coloured,non blood stained ,shortness of breath , generalized bodypains .

O- Febrile- Temp -102

icteric,pallor, subconjunctival hemorrhage

PR-122/ min ,regular

BP- 120/80 mmhg

RR-46 / min

Spo2- 92 % with high flow oxygen -14 litrs

RS- BAE present ,bilateral crepts + infraxillary ,infrascpular regions .

CvS- S1,S2 heard

P/ A soft

I/o -5500/2750 ml

A-

1-MODS- weils syndrome

2- Ventilator Associated pneumonia ?

P-

Iv fluids

Inj . ceftriaxone 1gm / IV/BD

Inj.doxy 100 mg / IV/BD

Inj.Meropenam 1gm /IV/BD

Intermittent CPAP

TEMP charting ,vitals monitoring.

10/11/21

weils syndrome MODS

S- patient is having fever spikes , cough with sputum yellow coloured,non blood stained , severe shortness of breath- , generalized bodypains .

He is dependant on CPAP ,

With high flow oxygen - sats -80 % and low

With CPAP -fio2 100%

O- Febrile- Temp -101

icteric,pallor, subconjunctival hemorrhage

PR-110/ min ,regular

BP- 120/80 mmhg

RR-46 / min

Spo2- 99 % with CPAP PC mode ,fio2-100 %

RS- BAE present ,bilateral crepts + , inframammary infraxillary ,infrascpular regions .

CvS- S1,S2 heard

P/ A soft

A-

1-MODS- weils syndrome

2- Ventilator Associated pneumonia

P-

Iv fluids

Inj . Colistin 2.5 MIU / iv /Stat given .

Inj.doxy 100 mg / IV/BD

Inj.Meropenam 1gm /IV/BD

Continuous CPAP mode

TEMP charting ,vitals monitoring.

11/11/21

weils syndrome MODS

VAP

S- patient is having fever spikes .

Complaining of Shortness of breath even on CPAP with 100% FIo2 .

O- Febrile- Temp -102 F

icteric,pallor, subconjunctival hemorrhage

PR-130/ min ,regular

BP- 130/80 mmhg

RR-34 / min

Spo2- 90 % with CPAP PC mode ,fio2-100 %

PEEP- 10 cm

Pinsp-20

RS- BAE present ,bilateral diffuse crepts +

CvS- S1,S2 heard

P/ A soft

A-

1-MODS- weils syndrome

2- Ventilator Associated pneumonia - Multi drug resistant gram negative bacteria ( klebsiella , acinetobacter )

P-

Iv fluids

Inj . Colistin 2.5 MIU / iv /BD .

Inj.Amikacin 1000 mg/IV/OD

Inj.doxy 100 mg / IV/BD

Inj.Meropenam 1gm /IV/BD

Continuous CPAP mode

TEMP charting ,vitals monitoring.

He might get intubated again .

CPR NOTES

IN VIEW OF FALL IN SATURATIONS WITH NO CENTRAL AND PERIPHERAL PULSES AND BPBNOT RECORDABLE AN IMMEDIATE CPR IN INITIATED ACCORDING TO ACLS GUIDLINES

11:00 AM BP/PR NOT RECORDABLE CPR STARTED 1 CC ADRENALINE GIVEN

CPR WAS CONTINUED TILL 11:35 AM WITH 1 CC ADRENALINE EVERY 5 MINS STILL BP AND PR NOT RECORDABLE AND CPR STOPPED

INSPITE OF ALL THE ABOVE RESUSCITATIVE EFFEORTS THE PATIENT COULDN'T BE REVIVED BACK AND ECG SHOWS FLAT LINE AND DECLARED DEATH ON 11/11/21 AT 11:36 AM

CAUSE OF DEATH: VENTILATOR ASSOCIATED PNEUMONIA , SEVERE ARDS,DIFFUSE ALVEOLAR HEMORRHAGES , SEPTIC SHOCK WITH MODS 2° TO LEPTOSPIROSIS

Death notes :-

45 YAER OLD KALE PATIENT DIAGNOSED WITH SEPETIC SHOCK WITH MODS 2° TO LEPTOSPIROSIS SEVERE ARDS 2° TO ? VENTILATORY ASSOCIATED PNEUMONIA ? DIFFUSE ALVEOLAR HEMORRHAGE ON 11/11/21 AT 11:00 AM PATIENT SUDDENLY BECAME UNCONSCIOUS WITH BP AND PULSE NOT RECORDABLE ,AN IMMEDIATE CPR IS INITIATED ACCORDING TO ACLS GUIDLINES . PATIENT WAS RE INTUBATED WITH FT NO 7.0 AND ADEQUATE RESUSCITATION WAS DONE INSPITE OF ALL THE ABOVE RESUSCITATIVE EFFORTS PATIENT COULDN'T REVIVED AND DECLARED DEAD ON 11/11/21 AT 11:36 PM

IMMEDIATE CAUSE:

1. SEVERE ARDS 2° TO VENTILATOR ASSOCIATED PNEUMONIA

ATECEDENT CAUSE: 2.SEPTIC SHOCK WITH MODS 2° TO LEPTOSPIROSIS

Day wise ABG reports

2/11/21 , 8.36pm