A 58 yr old male with sepsis 20/04/2021

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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 diagnosis and treatment plan.

A 58 YR OLD MALE WITH SEPSIS SECONDARY TO D5-D6 SPONDYLODISCITIS

Chief complaints:

• Weakness of bilateral lower limbs since 5 days

History of present illness :

• Patient was apaprently asymptomatic a week back

• 1 year back, he was diagnosed with HTN and was started on Tab TELMA 40mg + Chlorthalidone 6.25mg

• 2 months back he got diagnosed with Covid and received treatment for 1 week and was in home isolation

• On 21st March 2021 , he had fever for which he visited a local hospital and was diagnosed with dengue fever, he was admitted till 23rd March after which he got discharged.

• After getting discharged, he started to experience lower back ache which would be present throughout the day, not radiating.

• On April 12th , he paid a visit to a doctor in Khammam and was given pain killers.

• His LBA increased over the next 3 days.

• On April 15th , he paid a visit to an orthopaedician in khammam and was diagnosed with ankylosing spondylitis and was prescribed oral medications of Indomethacin, Ultracet and Bio D3.

After taking these medications, his pain did not reduce.

• On April16th , he took Diclofenac injections from a local RMP after which he could get a good night's sleep

• On April 17th , he started to even complain of bilateral knee joint pains along with left shoulder pain.

He took his second dose of injection Diclofenac

• He was able to walk with support, with the help of a stick on 17th

• From 18th of April, he even found it difficult to get up from his bed

He is able to make slight movements of his bilateral lower limbs.

He has no complaints of tingling, numbness, pins and needles like sensation.

• No involvement of bowel and bladder.

• No history of tingling and numbness

History of past illness:

• k/c/o HTN since 1 year and on tab. CTD-T 6.25/40mg ( telma 40mg + Chlorthalidone 6.25 mg)

• No history of DM, asthma, Epilepsy, thyroid

Treatment history:

• Has a treatment history of HTN since 1 yr

• Has no treatment history of DM, asthma, cancer, stroke, hormones, surgery, chemoradiation, Antibiotics, CAD, TB, blood transfusion

Personal history:

• He is a farmer, married and a resident of Nalgonda

• Follows mixed diet

• Has regular bowel habits and normal micturition

• Has no known allergies

• Is alcoholic

Family history:

• Has no family history of DM, HTN, asthma, CAD, stroke, cancer, TB

Vitals:

• PR - 110bpm

• BP - 120/80mmHg

• RR - 17cpm

• SpO2 - 98% on RA

• Temperature - Afebrile

Systemic examination:

A. Central Nervous system

• HMF intact

• Tenderness of bilateral knee joint +

• Tenderness in sternal region +

• Tone - Normal

• Power -

Right Left

UL 5/5 5/5

LL 2/5 2/5

• Reflexes -

B 3+ 3+

T 3+ 3+

S 3+ 3+

K 2+ 2+

A + +

P Flexion Bilaterally

• Sensory -

Fine touch +

Crude touch +

Proprioception +

Vibration +

B. Respiratory system

• Lungs - clear

C. Per Abdomen

• Soft

• Non tender

• Bowel sounds +

• Has central obesity

D. Cardiovascular system

• S1 and S2 heard

Probable Diagnosis :

SEPSIS SECONDARY TO D5-D6 SPONDYLODISCITIS WITH PRE-VERTEBRAL AND PARAVERTEBRAL, EPIDURAL ABSCESS AND SEPTIC ARTHRITIS

SECONDARY TO ? STAPHAREUS

? TB

? HTN

Investigations :

On 21.4.21

On 22.4.21

On 23.4.21

On 24.4.21

On 25.4.21

On 26.4.21

Treatment :

• Inj. Piptaz 4.5 gm/IV /QID

• Inj. Gentamycin 80mg/IV/TID

• Inj. Tramadol 1 AMP I'M 100ml NS/IV/SOS

• Inj. Neomol 1g/IV/SOS

• Tab. PCM 650mg /PO/SOS

• Inj. PAN 40mg /IV/OD

• IVF NS and RL @ 100ml/hr

• Tab. Etoz 90mg PO/OD

• Inj. Clindamycin 600mg /IV/TID

• Inj. Optineuron 1 AMP in 100ml/NS/OD

• Tab. Amlong 5mg /PO/OD

• Inj. Linezolid 600mg/BD

SOAP NOTES

ICU : 5 BED

S : Pain in knee joints

O :

Temperature : 98.6 F

BP : 160/90 mmHg

PR : 90bpm

RR : 18 cpm

SPO2 : 99%

CVS : S1 and S2 heard

CNS : HMF intact

UPPER LIMB : 5/5 bilateral

LOWER LIMB : 3/5 bilateral