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75M SEPTIC SHOCK SECONDARY TO PYOGENIC LIVER ABCESS

 

75 year male resident of Gudrampally was bought to casualty with

Complains of : Difficulty breathing since one day

Patient was apparently asymptomatic until 4 days ago then had complains of generalised fever high grade, insidious onset associated with chills, no diurnal variations relieved with medications.

Since yesterday patient had complains of shortness of breath, bilateral pedal edema (pitting) and decreased urine output

No complains of chest pain, cough, cold

No complains of burning micturition

No complains of pain abdomen, loose stools, nausea, vomitings

PAST HISTORY

History of ulcer on left lower limb one month ago treated with herbal medication

Not a known case of hypertension, diabetes, thyroid disorder, CAD, CVA, TB, Epilepsy 

PERSONAL HISTORY

Married

Appetite: lost

Diet : Non Vegeterian

Bowel: regular 

Micturition : decreased urine output

Habits : regular  toddy drinker since 30 years

Tobacco: 2/day since 30 years

No significant family history

GENERAL EXAMINATION

No pallor, icterus, cyanosis, clubbing, lymphadenopathy

Bilateral pedal edema (pitting type) 

Temperature: 97.6F

Pulse rate: 130bpm

Respiratory rate: 26cpm

BP : 90/60mmhg

Spo2: 98% at room air

GRBS: 98 mg/dl

CVS

CARDIOVASCULAR EXAMINATION 

INSPECTION:

No Precordial bulge

Visible apical pulse 

JVP  not elevated

PALPATION:

Apex beat felt in 5th ICS  medial to midclavicular line

No Parasternal heave 

AUSCULTATION:

S1S2 heard

No murmur

RESPIRATORY EXAMINATION

Inspection: 

Chest is elliptical, bilaterally symmetrical.

Trachea is central

Movement of chest bilateral symmetrical 

No scars, sinuses or visible pulsations  

Palpation: 

All Inspectory findings are confirmed

Apex beat felt in 6th Inter Coastal Space Medial to midclavicular line

Percussion:

All areas are resonant on percussion.

Auscultation:

Bilateral air entry present

Decreased breath sounds at right interscapular area,infrascapular area, infraxillary area

PER ABDOMEN

INSPECTION:

Shape of abdomen distended

Umbilicus everted 

Symmetrical movements in all quadrants with respiration 

No visible pulsations,peristalsis,dilated veins .

PALPATION:

No local rise of temperature

Tenderness in  suprapubic region +

 Rigidity

No organomegaly 

PERCUSSION

•Shifting dullness positive 

•Fluid thrill absent 

AUSCULTATION

• Bowel sounds present.

•No bruit or venous hum.

CNS

Higher mental functions intact

•Pt is irritable and oriented to place, time and person

•Bilateral pupils: Normal in size and reacting to light.

•Sensory system: normal in all 4 limbs

•Motor system: normal tone in all four limbs and power 5/5 in all limbs

•Reflexes: Normal deep tendon reflexes and Plantars are Flexors.

PROVISIONAL DIAGNOSIS: ? SEPTIC SHOCK








ABG

pH : 7.22

pCo2: 108

pO2: 108

Hco3: 9.2

Blood group: O positive 

RBS: 80

ESR: 40

CRP: positive (4.8mg/dl)

Anti HCV - non reactive

HbSag: Negative

HIV1/2 : non reactive

Hb: 12.8
TLC: 22000 cells/cumm
NEUTROPHILS: 93
LYMPHOCYTES: 04
EOSINOPHILS: 09
MONOCYTES: 03
BASOPHILS:00
RBC: 3.84 millions/cumm
PLATELET COUNT: 65000/cu.mm

LFT
TOTAL BILIRUBIN: 3mg/dl
DIRECT BILIRUBIN: 2.34mg/dl
SGOT: 353 IU/L
SGPT: 205 IU/L
ALP : 294 IU/L
TOTAL PROTEINS: 5.3mg/dl
ALBUMIN: 1.96 gm/dl
A/G RATIO: 0.59

RFT
UREA : 171mg/dl
CREATININE: 2mg/dl
SODIUM: 137mEq/L
POTASSIUM: 3.7mEq/L
CHLORIDE: 99mEq/L

USG 





IMPRESSION: 
Multiple liver abscess
Moderate ascites
Gall bladder sludge noted
Bilateral grade 1 RPD changes with right renal cortical cysts and left renal calculi

Pulmonology referal was taken in view of decreased breath sounds 

General surgery referal was taken in view of rigid abdomen




TREATMENT GIVEN

IV FLUIDS NS @100ml/hr
INJ SODIUM BICARBONATE 50mEq IV/STAT
INJ NORAD 0.96mcg/hr
INJ PIPTAZ 4.5g IV/STAT


DEATH SUMMARY
78 year male was bought to casualty with complains of Fever since 4 days and SOB, pedal edema, decreased urine output since two days at time of presentation. Patient vitals were BP: non recordable ——90/60 after two pints NS bolus, pulse rate: 106bpm, respiratory rate 27cpm, temp:97.8F, GRBS:98mg/dl
ABG at room air PH:7.22 pco2: 22.9, po2:109, Hco3: 9.2. IV Bicarbonate correction was done.
General surgery referal was taken in view of rigid and tense abdomen, advised USG abdomen and pelvis
Chest X-ray was taken bedside and Pulmo referal was taken in view of decreased breath sounds, advised for USG chest
In view of low BP patient was started on NORAD @6ml/hr. Despite noradrenaline infusion and IV fluids BP was 80/50mmhg
USG abdomen showed multiple liver abscess, moderate ascitis, gall bladder sludge, bilateral grade 1 RPD changes, right renal cortical cyst, left renal calculi 4mm in mid pole
At. 3:45pm patient had absent pulses and cpr was initiated and continued. Despite all the efforts patient could not be revived and declared death at 4:12pm

IMMEDIATE CAUSE OF DEATH: Refractory hypotension secondary to ?septic shock
Antecedent cause:
 ?pyogenic liver abscess, 
Moderate ascites,
Left renal calculi 
Prerenal aki
Metabolic acidosis
Hepatitis
?hydropneumothorax

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