45 yr/ M with Fever ,Vomitings and Hypotension

 

I am Saranya ,a final year MBBS student.

Greetings to all my readers;

This is an elog documenting the patients that I witness during my Clinical Postings to enforce a greater patient centered learning .

 

 DEIDENTIFICATION : 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

 

Introduction :  

Here we shall discuss about a patient who is a 45 year old farmer hailing from South India .

 

PRESENTING PICTURE OF THE PATIENT :

Day 1

The patient presented to the OPD with complaints of

 

-Fever since 4 days 

-Body pains since 3 days 

-Reduced urine since 2 days 

-Vomiting yesterday 

-Black stools since morning 

 

Please note : Patient was hypotension (70/40 mm Hg B.p was recorded ) on presentation and he was agitated, dyspneic ,was complaining of headache and was thirsty

 

 

Sequence of events which led to the presentation of the patient :

Patient is a farmer hence works in the farm from morning till eve, until 4 days back ( 29^th October 2021 ) when he developed fever along with cough ,headache. He received medications given by the local physician but nothing much changed

A day or two later he developed muscle pains which he described to be in both his arms and thighs and the fever was back again

He took medications for one more day

But nothing seemed to improve

Also a new addition to his problems were vomiting

This was when he was taken to Hospital1 where the attenders  gave information about the patient being given fluids but they felt that proper care was not being taken and hence they brought the patient to Hospital2

 

When we asked more questions, we found out that he had passed much less urine than he usually does since the past couple of days and that day he had passed stools which were black in colour.

 

Daily Routine of the patient :

 

He normally used to get up at 5.00 am ,freshen up and go to the fields , in the afternoon at around 1.30pm he would return home for lunch, post which he took rest for an hour, by this time it would be around 3.00 pm

He would again go out for work for another 2 hours and then return home , take a bath ,have his meal .Many a times he would go out to drink alcohol in the evenings. After spending an hour or so talking to his wife and two sons over the meal

And then he would sleep by 9.00 pm.

 

Some more details about his complaints

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

 

H/o 2 episodes of non projectile, non bilious, blood tinged vomiting yesterday 

 

-Hematuria since morning

-1 episode of black tarry stool in the morning

-Reduced urine output since morning

 

Addictions :

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. 

 

GENERAL EXAMINATION :

PR - 118 bpm

BP- 70 /40 mm Hg ( started on fluids and ionotropes)

RR - 25 cpm

Spo2 - 92% on Room air

Afebrile

Lungs -

Inspiratory crepitations in Bilteral IAA,ISA

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

NOTE : There is history of change in water source and also contamination of right ankle with rat's urine in his farmlands 

Fever Chart

Fever Chart (updated : Day 6 of Admission 8th November 2021 )

Chest X ray on Day 2 (4th November 2021 )

Chest Xray on Day 4 of Admission : 6th November

Some textbook description of Weil's Disease :

Courtesy declaration:  The following images are not original and have been taken for reference from the below mentioned source .

 Source : Davidson's Principles and Practice of Medicine

23^rd Edition

Infectious Diseases

 Note : On 5th November 2021 evening ,patient developed Cardiac Arrest owing to the Myocarditis entity and was revived by cardiopulmonary resuscitation.

UPDATE :8th November 2021

http://prashanthsharma101.blogspot.com/2021/11/case-of-45-years-old-man.html

 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.

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 

1-MODS- weils syndrome 

2- Ventilator Associated pneumonia ? 

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 .