Case study

Case study 46 yrs old male from kotahen presented with a history of fever, Body aches and headache for 4 days. This was associated with vomiting for past 1 day duration. He didnt have significant past medical or past surgical history. No known history of drug or food allergies.He is an alcoholic and non smoker.On examination:Averagely built male, He was in moderate pain. Conjunctivae pink, no clubbing, no icterus, no peripheral or central cyanosis.Blood pressure 90/70 mmHg, Pulse 72 /min, Apex not shifted, No murmurs.Rest of the systemic examination normal.

Day 1 (2010.08.11)

ALT 56.2 U/LAST 62.2 U/LBlood Urea 14.7 mg/dlS. Creatinine 0.83 mg/dlNa 136 mmol/lK - 3.69 mmol/lCRP 189.1 mg/dlWBC 8.8Neu 69.8%Hb 13.9 g/dlMCV 79.9 flPlt - 130 Day 1 (2010.08.11)

MxOmit IV fluidsIncrease oral intakeInput output chartParacetamol 1G s.o.sO.Ciprofloxacin 500mg bdDormicum 7.5mg nocte s.o.s

Day 2 (2010.08.12)Bowel opened 3 times.Vomited once. On examinationNo icterusBP 110 / 80 mmHgAbdomen soft, tender and mildly distendedRepeat FBC and UFRPt was arranged for x ray KUB(Dulcolax 3 tab nocte)

Day 2 (2010.08.12)

WBC 9.7Neu 69 %Hb 13.4 g/dlMCV 81.8 fLPLT 120PCV 37.4%UFR Protein (+30 mg/dl)Pus cells (1-5 / H.P.F)RBC (8 10 / H.P.F)

Plan

Input output chart.Continue the medication.Day 3 (2010 / 08 / 13)Pt is complaining of severe pain in Right side lower abdomen and Right groin, not colicky in nature.No loin pain no radiation of pain.Passing loose stools. Bowel sounds exaggerated.On examinationNo icterusBP 120 / 80 mmHgS1 heart sound loud, short Mid Diastolic Murmur(Mitral stenosis)Abdomen soft, tender and mildly distended.

Day 3 (2010.08.13)

RBS - 126 mg / dl at 7 amUrine for Bilirubin NilUrine for Urobilinogen Increased amounts.Total Bilirubin 1.0 mg/dl (0.2 1.4)ALT 69.9 U/LAST 68.8 U/L

Clinical DiagnosisIntra abdominal infection not suggestive of appendicitis, Inflammatory bowel disease or typhoid.Mild Mitral stenosis.

Plan For painIM Pethidine 75mg stat.IM Phenegren 25mg stat.Referred to general surgeon.

Ciprofloxacin omitted and start Ceftriaxone 2G I.V stat & 1G I.V b.d.I.V fluids Hartmans 50ml I.V and 5% Dextrose 50ml I.V at 6p.m and 10 p.mNo solid foods. Can take fluids like king coconut, Orange juice, Plain tea, Jam.Dormicum 7.5mg given at 10 pm.

Day 4 (2010.08.14)Bowel opening 8 times. Watery stools, no blood in the stools. Temperature spikes.On examinationHeart S1 loud, Short Mid diastolic murmur.Abdomen distended. Flank dullness +, Shifting dullness + .Tenderness on R sided abdomen.Problems detected: Ascites due to bacterial infection.

Arrange for USS of the abdomen.USS abd: subacute intestinal obstruction.?following acute appendicites.

Microbiology lab informed Blood culture positive for Gram negative Bacilli.Day 4 (2010.08.14)Stool full report Consistency watery with mucusRBC 4-6 /H.P.FPUS 25-30 /H.P.FCysts Nil

Total protein 64.8 g/lAlbumin 30.5 g/lGlobulin 34.3 g/lA/G ratio 0.9Total Bilirubin 0.6 mg/dlDirect Bilirubin 0.4 mg/dl Day 4 (2010.08.14)UFRProtein - +100 mg/dlPus cells 1-5 / H.P.FRBC 4-6 /H.P.FCasts Granular casts Crystals NilBlood culture Gram negative BacilliPT 18.8 seconds I.N.R 1.52ESR (1st hour) 30 mmFBCWBC 9.4Neu 83.3%Hb 14.5 g/dlMCV 80.8fLPLT - 151Day 5 (2010.10.15)Still have fever. Not in distress. Tongue moist.On examinationBP 130/80 mmHg, Pulse 76/min ectopics+Mid diastolic murmur heard over the mitral area.Abdomen mildly distended. No guarding, No rigidity, No rebound tenderness.Day 5 (2010.08.15)CRP 205.3 mg/dlWidal test (S.A.T) S.Paratyphi AH: +1/80Blood urea 58.6mg/dlSodium 129 mmol/lPotassium 3.63 mmol/lS. Creatinine 0.77 mg/dlGFR 116ml/min/1.73m2Hepatitis B surface antigen NegativeBlood culture Salmonella Enteritica sub type Paratyphi AABST (Ampicillin, Co-Trimoxazole, Cefuroxime, Ceftriaxone, Chloramphenicol) - sensitive

Diagnosis Sepsis : focus Intraabdominal.X ray abdomen: fluid levels.Diarrhoea.INR value elevated.Mild mitral stenosis.

Plan Gentamycin 240mg in 100ml of normal saline IV over 1 hour.Continue Ceftriaxone 1G I.V. b.dConsider Tazocin 4.5G I.V. 8 hourly2 units of FFP given over 2 hours.1 unit of Hartmans solution given over 3 hours.Plan Clinical picture and investigations confirm a diagnosis of Paratyphoid.This seem to be a severe episode.Used High dose Ceftriaxone 2 G I.V. b.d may be reduced to 1 G I.V. b.d when temperature remain normal for over 24 hours.Maintain fluid balance + (K+)Avoid solids for at least 48 72 hrs after temperature normal.On discharge consider Chloramphenicol 500mg qds for I week.Pateint has mild mitral stenosis.I.V fluids Hartmans 500ml I.V. 3.30pm 6pm5% Dextrose 500ml I.V. 6 pm 9pmN. saline 500ml I.V. 9pm 4am5% Dextrose 500ml I.V. 4am 8amN.saline 500ml I.V. 8am 12noon(1.5G kCl (20 mEq KCl)

Day 6 (2010.08.16)BP 100/60 mmHgTemp 100 FNot dehydrated.Bowel opened 3 times.Continue medication and I.V fluids + KCl and repeat serum electrolytes.Oral fluids given (Jeevani and king coconut water)Notification done.

Day 6 (2010.08.16)8amSodium 135 mmol/lPotassium 3.66mmol/l

5pmSodium 133mmol/lPotassium 4-16mmol/l2010.08.17BP 110/70 mmHgBowel opened once in the morning.To arrange Chloramphenicol 500mg 6hourly for 7 days on discharge.2010.08.18BP 110/70 mmHgNo fever Bowel opened twice, semi solid stools.Abdomen not distended.No tenderness.

On discharge Chloramphenicol 500mg q.d.s for 7 days.

Problems to be further addressed and follow up.DyslipidemiaMitral stenosis