A 56 year old with shock secondary to sepsis UTI

 This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS 

Case presentation 

Patient was bought to the casualty with the complaint of 

Altered sensorium since 2 days

Decreased urine output since 2 days 

Shortness of breath since 1 day

History of presenting illness 

Pt was apparently asymptomatic 2 days back then he developed decreased urine output .

Foleys catherization was done outside, patient pulled the foleys catheter which caused urethral rupture .later catheterisation was done under cystoscope guidance . Altered sensorium since 2 days, irritable behaviour, not able to identify attenders , shortness of breath since 1 day insidious in onset and gradually progressive ( grade 1- grade 3)

No h/o Orthopnea 

No h/o fever,vomitings loose stools , pain abdomen 

Past history-

K/c/o type 2 DM , and HTN since 7 years ( on unknown medication ) 

DIET: MIXED

SLEEP: ADEQUATE 

BOWEL: REGULAR

BLADDER:  DECREASED MICTURATION

NO ALLERGIES 

ADDICTIONS - ALCOHOL 90ml twice or thrice in a WEEK since 

FAMILY HISTORY: 

NO H/O SIMILAR COMPLAINTS IN THE FAMILY 

THE PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

MODERATELY BUILT AND NOURISHED 

NO SIGNS OF  ICTERUS ,CYANOSIS, CLULBBING of fingers , EDEMA of feet ( non pitting )   

VITALS: 

TEMP: AFEBRILE 

PR: 94BPM 

RR: 36 CPM 

BP: 90/60 MM HG

SPO2: 95% @ RA 

GRBS: 95 MG/DL

RS: BAE+, NVBS 

TRACHEA: CENTRAL 

NO DYSPNOEA AND WHEEZE 

NO RHONCHI 

CNS: 

LEVEL OF CONSCIOUSNESS: CONSCIOUS, ALERT 

SPEECH: SLURRED

NECK STIFFNESS ABSENT 

KERNINGS SIGN ABSENT 

CRANIAL NERVES: NORMAL 

MOTOR SYSTEM: NORMAL 

SENSORY SYSTEM: NORMAL 

GCS: 15/15 E4V5M6 

TONE: 

UL: NORMAL 

LL: NORMAL 

POWER: 

UL: BOTH 4/5

LL: BOTH 4/5

REFLEXES:             RT              LT

B:                           +2              +2

T:                           +2              +2

S:                           +1              +1

K:                           +2              +2

A:                           +2              +2

INVESTIGATIONS 

HB 9.5

TLC 6300

PCV 27.1

MCV 63.1

PLT 18000

TB 6.54

DB 5.33

UREA 99

CREATININE-  3.5 

NA- 135

K -4.8

Magnesium-2.0

PROVISIONAL DIAGNOSIS 

SHOCK SECONDARY TO SEPSIS UTI

TREATMENT 

IV FLUIDS NS BOLUS

INJ MEROPENIUM

INJ LINEZOLID

INJ OPTINEURON

INJ SOD BICARBONATE