65 YEAR OLD MALE WITH LOWER LIMB CELLULITIS AND SEPTIC SHOCK

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I am Nomika Alli (Roll no 179) of 8th Sem MBBS. 

A 65 year old Male, R/O Nalgonda, came to the OPD on 13th August 2023 with complaints of Fever since 6 days and lower limb swelling and pain since 2 days

HISTORY OF PRESENT ILLNESS:

Patient has developed fever associated with chills one week back , continuous , relieved on taking paracetamol. After 4 days of onset of fever, patient developed swelling of left lower limb which initially started at level of foot and then gradually progressed to below knee joint which is a/o pricking type of pain.

No aggravating and relieving factors.

Associated with discharge at left greater toe i.e; seropurulent in nature

H/O draining wound/ sinus (watery / pus ??) with mild edema from last 20 yrs near left ankle after an injury to left ankle/ toe?? 20 yrs back. Dressing is done few times in this span of 20 yrs

No H/O pale limbs , SOB, rash, lightheadedness

No H/O vomiting, loss of appetite, burning micturition.

His daily routine is waking up at 6: 00 am, drinks tea at 7:00 am, breakfast as rice and curry at 8:00 am . He used to have his lunch as rice and curry  at 1: 00 pm .He usually haves his dinner as rice and curry at 8:00pm and goes to bed by 9:00 pm.

The patient used to lead a normal life before this episode of fever and used to walk normally and freely.

HISTORY OF PAST ILLNESS:

N/K/C/O DM, HTN, Asthma, CAD, CVD, Thyroid, epilepsy

H/O TB (Pulmonary koch's) 8 yrs ago for which treatment was taken. (ATT drugs)

H/O ulcer at left ankle  20yrs ago

Patient is Deaf since childhood. (cong / acquired???)

SURGICAL HISTORY: H/o cataract surgery for rt eye 

FAMILY HISTORY: 

N/K/C/O DM, HTN, Asthma, Epilepsy, CAD, CVD

This patient's elder brothers died with lower limb related disorders/ pathologies?? few years back. 

His younger brother passed away with stomach TB when he was 25 yrs .

PERSONAL HISTORY:

Married

Daily wage laborer by occupation. stopped working few yrs ago.

Diet: Mixed

Appetite: Normal

Sleep: adequate

Bowel and bladder movements: Regular

Addictions: Alcohol occasionally

Allergies: no known

GENERAL EXAMINATION: 

Patient is conscious, coherent, cooperative to time , place, person.

Ht: 155cm      Wt: 58 kg

Pallor: present 

Icterus: absent

Clubbing: absent

Cyanosis: absent

Koilonychia: absent

Lymphadenopathy: absent

Edema: left lower limb cellulitis

right LL edema

Vitals: Temp: 99.4F

BP: 70/40 mmHg

PR: 121 bpm

RR: 21 cpm

SpO2: 90%

GRBS: 63 mg%

SYSTEMIC EXAMINATION:

Limb examination (L/E)- 

• Left lower limb edema upto knee joint
• local raise of temperature
• tenderness present
• edema: pitting type
• peripheral pulses not felt due to edema

    

CVS:

S1 S2 heard

No murmurs

No thrills

RS:

Crepts +

Lt. IAA

No dyspnoea

No wheeze

Central position of trachea

NVBS +

ABDOMEN:

Shape of abdomen: scaphoid

No tenderness

No palpable mass

Hernial orifices: Right inguinal hernia present

No bruits

Liver and spleen- not palpable

Bowel sounds heard

CNS:

Conscious

no neck stiffness

kernig's sign negative

cranial nerves: normal

motor - intact

sensory - intact

Glasgow scale E4V3M6 = 13/15

Cerebellar signs- no

Finger nose in coordination: yes

knee heel in coordination: yes

LIMB SCORE: 

Left LL: -1/5 (Left LL monoplegia)

Right LL: -4/5 

Upper limbs: -2/5

Paraplegia?? Hemiplegia?/ Quadriparesis??

Knee hammer :rt knee reflex: elicited sometimes

ankle reflex: edema and pain+

left knee: pain

MUSCULOSKELETAL SYSTEM: normal

SKIN: normal

ENT: normal

TOOTH & ORAL CAVITY: normal

PHYSICAL EXAMINATION:

Dressed lower limb with MgSO4

Rt. knee: resembling leathery appearance on touching

indurated

peau d orange???

2° vitiligo

Left LL:

Left knee: smooth to touch

Pallor present

edema of both wrists and hands due to thrombus

INVESTIGATIONS:

Investigations done on 12th august 2023(local hospital)

CBP: Increased total WBC count 

decreased Hb

LFT: increased BR

increased S. AKP

increased SGOT

RFT: increased S. creatinine

increased uric acid

increased blood urea

on 13th August 2023

decreased Hb, increased total count, 

increased neutrophils

decreased lymphocytes

CUE:

ABG:

ANTI HCV antibodies:

APTT:

BT & CT

Blood grouping:

Blood lactate:

Blood sugar random:

HBsAg

HIV:

LFT:

Increased total BR, direct BR, AKP

too decreased total proteins, albumin

PT:

RFT:

urinary urea increased, increased creatinine, hypocalcemia

BLOOD UREA:

increased

ECG:

15th aug 2023

HEMOGRAM: decreased Hb, increased total count, 

increased neutrophils

decreased lymphocytes

ECG: 15-8-23

S.Creatinine

16-8-23

HEMOGRAM: decreased Hb, increased total count, 

increased neutrophils

decreased lymphocytes

RFT: Increased urea, hypocalcemia, hypokalemia,

2D ECHO DOPPLER:

SINUS ARRHYTHMIA

Moderate to severe MR+, eccentric MR+, Moderate TR+ with PAH, 

Grade I diastolic dysfunction, NO PE.

Calcified AV, thickened AV, Dilated L.A/ R.A

IVC size(1.68 cm) dilated collapsing

CHEST X RAY:

lower lobe consolidations

HEMOGRAM: decreased Hb, increased total count, 

increased neutrophils

decreased lymphocytes

RFT:

USG:

renal cortical cyst

mild pleural effusion (l>r)

B/L grade 1 RFD changes

S. magnesium

Urinary chloride

Urinary potassium

Urine sodium

Pus culture :- coagulase negative staphylococci 

USG chest: Free fluid in rt pleural space and left (r>l)

blood culture:

urine culture:

17-8-23

Hemogram: decreased Hb, Increased total count, decreased lymphocytes,

decreased PCV, decreased RBC count

LFT: increased total BR, Direct BR, AKP increased (4x),

too decreased total proteins and albumin

S. electrolytes

Peripheral smear:

Reticulocyte count:

18-8-23

Hemogram: Decreased Hb, Increased total count, 

decreased lymphocytes, absent eosinophils,

 decreased PCV,  low RBC count

S. electrolytes:

19-8-23

Hemogram: 

decreased Hb , increased total count, 

decreased lymphocytes, low PCV, low RBC count

RFT: decreased uric acid, hypocalcemia

X ray 

20-8-23

21-8-23

2D echo 

PROVISIONAL DIAGNOSIS:

SEPTIC SHOCK 2° LOWER LIMB CELLULITIS 

WITH  HYPOKALEMIA (under evaluation )
ć AKI (RESOLVING) 

Acute on chronic cellulitis??

INFECTIVE ENDOCARDITIS???? (no vegetations found in echo )

With BILATERAL LOWER LOBES CONSOLIDATION

RIGHT MODERATE PLEURAL EFFUSION WITH COLLAPSE AND CONSOLIDATION 

LEFT MILD PLEURAL EFFUSION 

H/O PULMONARY KOCH'S 8 YRS BACK

H/O RHD??

MANAGEMENT:

Day 1 : (13-8)

Inj peptaz 

Inj pantop 

Inj zofer 

Inj tramadol

IVF 20RL, 20NS, 20.5%D

Lower limb end evaluation 

Mgso4 + glycerine dressing 

T/BP/PR hourly monitoring 

GRBS 4th hrly 

I/O charting 

Inform surgery sos 

Day 2 (14-8):

Soft diet 

Inj noradrenaline 

IVF 30RL , 10NS , 100 NS 

Inj peptaz 

Inj pantop 

Inj zofer 

Inj tramadol

Lower limb end evaluation 

Mgso4 + glycerine dressing 

T/BP/PR hourly monitoring 

GRBS 4th hrly 

I/O charting 

Day 3 (15-8):

Soft diet 

IVF 10 RL 10 NS @75ml/hr

Inj piptaz 

Inj norad 

Inj pan 40 

Inj tramadol 

Inj Neomol 1gm/IV (if temp >101F)

Inj zofer 

Left LL end elevation 

Mgso4 dressing

BP,PR,RR,SpO2 monitoring hourly 

GRBS 4th hrly 

Strict I/O charting 

Day 4(16-8):

Soft diet 

IVF 10 RL 10 NS @75ml/hr

Inj piptaz 

Inj norad 

Inj pan 40 

Inj tramadol 

Inj Neomol 1gm/IV (if temp >101F)

T.PCM

Inj zofer 

Left LL end elevation 

Mgso4 dressing

BP,PR,RR,SpO2 monitoring 4th hourly 

GRBS 4th hrly 

Strict I/O charting 

Syp Cremaffin 

Syp potklor 15ml 

Day 5(17-8):

IVF 30NS @50ml/hr 

Inj piptaz 

Inj norad 

Inj pan 40 

Inj Neomol 1gm/IV (if temp >101F)

T.PCM

Left LL end elevation 

Mgso4 dressing

BP,PR,RR,SpO2 monitoring 2 hourly 

GRBS 4th hrly 

Strict I/O charting 

Syp potklor 15ml 

2 egg whites daily 

Protein powder 2 cups in 1 glass of milk 

Inj Metrogyl 500mg 

Day 6(18-8):

IVF 30NS 50ml/hr

Inj piptaz 

Inj norad 

Inj pan 40 

Inj Neomol 1gm/IV (if temp >101F)

T.PCM

Inj zofer 

Left LL end elevation 

Mgso4 dressing

BP,PR,RR,SpO2 monitoring hourly 

GRBS 4th hrly 

Strict I/O charting 

Syp potklor 

2 egg whites daily 

Protein powder 2 cups in glass of milk or water 

T orofer xt 

Day 7(19-8):

IVF NS @50ml/hr

Inj peptaz 

Inj metrogyl 

Inj neomol 

Inj norad 

T PCM 

Syp potklor

2 egg whites daily 

Protein powder 2 cups in glass of milk or water 

T orofer xt 

GRBS Monitoring 

BP,PR,RR monitoring hrly 

Strict I/O charting 

Day 8(20-8)

IVF NS@50ml/hr

INJ PIPTAZ

INJ METROGYL

Inj Neomol

Inj Norad

T. PCM

T. orofer

Protein powder 2 spoons in 1 glass of water or milk

2 egg whites daily

GRBS monitoring 

BP, PR, RR hourly 

Temp monitoring 4th hrly

Strict I/O Charting

Day 9 (21-8)

IVF NS@50ml/hr

INJ PIPTAZ

INJ METROGYL

Inj Neomol

Inj Norad

T. PCM

T. orofer

Protein powder 2 spoons in 1 glass of water or milk

2 egg whites daily

GRBS monitoring 

BP, PR, RR 4th hourly 

Temp monitoring 4th hrly

Strict I/O Charting

Day 10 (22-8)

Lost this patient while treatment is going on. 🙏🏻