AGE : 57 Y/O MRN : 260952 DATE OF ADMISSION : 3/3/14 p/w bilateral leg swelling for 1/52 -worsening
fever for 1/7 -started today at hospital -claimed no fever at home
had nausea but no vomiting +poor oral intake, claimed d/t reduced appetite
otherwise, no abdominal pain no sob or chest pain no URTI/UTI sx no dirrhea/constipation no recent insect bite claimed recent fall at bathroom 2days ago
O/e alert,pink warm peripheries good pulse volume
V/s BP 123/59 PR 101 RR 24 SPO2 96% T 37.6 Dxt 7.0
Lungs clear CVS drnm P/a soft non tender
Lower limb examination:
bilateral leg odema up to mid shin +erythematous > right side +warm on touch +mild tender on palpation +no punctum seen no blood/pus discharge
ECG: SR, HR 92, + flattened T waves
US bilateral lower limb: no evidence of DVT
X-ray tibia/fibula: no fracture/dislocation, no gas shadow
Imp: bilateral lower limb cellulitis Ix Hb: 12/1 Wcc :6.1 Plt : 208 Urea : 1.5 K :3.8 Creat : 88 Alt : 32 Alp : 67 Fbs : 4.3
PLAN
Observe trend of viral fever Repeat FBC cm For iv. cloxacillin 1g stat qid Send septic work up
5/3/14 progress, pain reducing low grade fever not ambulating yet on IV cloxacillin day 2
o/e: alert & conscious comfortable not toxic looking not in respi distress dry lips pink warm peripheries good pulse volume crt<2sec
leg measurement: Left : 48 --> 43cm , eryhtematous, warm, non tender right: 52cm --> 48.5cm swollen, erythematous, warm & mild tender local exam of right lateral chest wall: wound about 4x4cm clean base no pus discharge
plan
take swab c&S For daily dressing of skin ulcer encourage ambulation s/c fondaparinux 2.5mg od for dvt prophylaxis 6/3/14 progress, pain reducing low grade fever not ambulating yet on IV cloxacillin day 4
o/e Vs: bp: 105/58 Hr 80 Rr 20 T: 37 Spo2 : 96
thromboplebitis on the right arm
Plan change venofix trace blood culture 7/3/14 progress leg : swelling reducing, claimed not painful anymore low grade temp due to thromplhebitis of the right arm, temp settle pt comfortable not tachypneic not tacycardic o/e Bp : 104/58 Hr : 77 Rr: 22 T: 37 Spo2 : 97
Plan: enc ambulation probe up refer chest physio
8/3/14 progress, pain reducing not ambulating yet on IV cloxacillin day 6 mild sob
o/e thromboplebitis on the right arm wound : having minimal d/c bilateral leg swelling reducing
Plan: cont cloxa take fbs
x Hb 10.1 Wcc 8.4 Plt 201 Urea 4.3 Na 131 K 3.8 Creat 222 Blood c+s : no growth Sputum c+s : no growth Urine c+s : candida sp Swab c+s: pseudomonas earoginosa 9/3/14 progress, pain reducing no fever on IV cloxacillin day 7 o/e Alert, conscious Not tacypneic
Lung : bibasal crept
Ix Hb : 10.1 Wcc : 10 Plt : 189 Urea : 6.2 Na : 128 K : 4.5 Creat : 316
imp: 1)bilateral lower limb cellulitis 2)aki secondary to possible dehaydration
PLAN cont cloxa 4 pint ns over 24h i/o charting rpt fbc , rp cm
10/3/14 progress, generalized abdominal pain , worst on suprapubic and right illiac fosa swab from previous wound : pseudomonas aeroginosa low grade fever worsening aki on IV cloxacillin i/o positive balance
lungs : bilateral ronchi
p/a non guarding ,non distended, b/s present
imp: 1) tro acute abdomen 2) aki secondary to dehyration 3) right lateral chest wall skin ulcer Ix Hb : 9.8 Wcc : 10 Plt : 201 Urea : 8.4 Na : 128 K : 4 Plt : 377
Plan to refer surgical tro acute abdomen/acute appendicitis, infected wound rpt septic w.u rpt xray abdomen change dvt prphylasis to clexane neb salbutamol stat and 4hourly abg t/o to acute knbm s/b surgical team
PA soft thick abdomen, tender over left lumbar and RIF during deep palpation
allow orally now syp lactulose 15mls TDS if still having persistent abdomen pain to keep patient NBM to reassess back cm cont medical plan 10/3/14 7.10pm Bp : 172/118, hr 92, rr 21, spo2 95% Dxt 4.4 11pm Bp: 98/57 , hr 106, rr 21, spo2 98%
11/3/14 7.30 am Bp : 62/29, hr 39, rr 21, spo2 71 Dxt : 7.8 7.47 am Bp, hr unrecordable
11/3/14 noted patient unresponsive at 7.25am pulse not palpable no spontaneous breathing bp unrecordable
was put on cardiac monitor , noted asystole cpr commenced for 30 minutes patient was intubated with ETT size 17 given adrenaline 4x
however after 30 minutes of resuscitation, pulse still not palpable cardiac monitor showed asystole no spontaneous breathing bp unrecordable pupils fixed dilated
unable to revive patient
pronounced death at 7.47am, 11/3/2014 cause of death: sepsis with multiorgan failure