47 yr old male with sepsis

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Case presentation:

47 yrs old male patient came to casualty with complaints C/O burning micturition since 15 days C/O fever , since 10 days 

vomitings since 3 days 

C/O pain abdomen, since yesterday ,in right hypochondrium,epigastric  and right lumbar region 

History of present illness:

Pt was apparently asymptomatic 15 days back,then complains C/O burning micturition since 15 days,no pain during micturition,

C/O fever ,high grade since 10 days associated with chills, relieved on medication ,there is evng rise of temp.

vomitings since 3 days 10 to 12 episodes/ day 

Bilious vomitings not associated with food particles  not associated with blood ,non projectile

C/O pain abdomen, since yesterday ,in right hypochondrium,epigastric  and right lumbar region relieved on medication,

Past history:

Known case of DM type 2 since 3 years, on tab metformin 500 mg od ,got diagnosed when he was admitted in hospital for renal calculi.

H/o TB 4 years back used ATT for 9 months 

Known case of renal caliculi 3 years back ,for which Surgery was done 

Not a k/c/o HTN EPILEPSY CVA CAD ASTHMA. 

Family history:

No history of DM, HTN CAD, CVA, asthma in the family

Personal history: 

Appetite: normal

Bowels: regular 

Bladder- burning micturition

 Regular alcoholic since 20 yrs (90ml/day)

Tobacco chewer since 20 yrs 

General examination: patient is conscious, coherent, altered ( ? Alcohol withdrawal)

No Pallor 

No icterus, cyanosis, clubbing,lymphadenopathy, edema

Vitals:

Temperature: 98.9F

Pulse: 80bpm

Respiratory rate: 19/ min

Bp: 100/60mm hg

Spo2: 98% at RA

GRBS: 85 mg%

Systemic examination: 

Cvs: S1 S2 heard no additional sounds or murmurs

Rs: NVBS

Abdomen: soft,non tender,no organomegaly

Cns: no focal neurological deficit

Provisional diagnosis:acute rt sided pyelonephritis

?Sepsis secondary to pyelonephritis

Investigations:

ecg on 22/12

ecg on 23/12

on 24/12

Treatment 

Day1

Inj piptaz 4.5 gm stat,followed by inj piptaz 2.25 gm iv TID

Inj pan 40 mg IV/bd

Inj zofer 4 mg IV /bd

Inj metrogyl 500 mg IV/of

IVF 2 NS bolus followed by 125ml/hr

Day2

Inj piptaz 2.25 mg IV/TID

Inj metrogyl 100 ml iv TID

Inj pan 40 mg IV of

Inj zofer 4 mg IV TID

Inj lasix 20 mg IV bd,if bp>110mm of hg

Inj optineuron 1 amp in 100 ml NS IV OD

Inj thiamine 1 amp in 100 NS IV bd

Infusion noradrenaline 2 amp in 49 ml NS at 15 ml/hr,titrate acc to bp

Infusion dopamine 1 amp in 45 ml NS at 2 ml/hr,titrate according to MAP,target MAp>65

IVF 2 N S,2 RL at 125ml/hr.

Day3

Inj piptaz 2.25 mg IV/TID

Inj metrogyl 100 ml iv TID

Inj pan 40 mg IV of

Inj zofer 4 mg IV TID

Inj lasix 20 mg IV bd,if bp>110mm of hg

Inj optineuron 1 amp in 100 ml NS IV OD

Inj thiamine 1 amp in 100 NS IV bd

Infusion noradrenaline 2 amp in 49 ml NS at 14ml/hr,titrate acc to bp

Infusion dopamine 1 amp in 45 ml NS at 2 ml/hr,titrate according to MAP,target MAp>65

IVF 2 N S,2 RL at 125ml/hr.

Syp lactulose 10 ml PO/HS