28M with SOB at rest and high grade fever spikes #CRBSI
https://venkatsaitodupunoori.blogspot.com/2022/06/ckd-on-mhd-this-is-online-e-log-book-to.html?m=1
Author : Dr. Venkat sai, Dr. Chandana, Dr. Sai Charan
A 30 year male presented with c/o grade 4 SOB,fever-high grade
June 13, 2022
CKD ON MHD
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Chief complaints:
A 30 year male auto driver by occupation presented 2days ago with c/o grade 4 SOB,fever-high grade since 5days.
HOPI:
Patient was apparantly asymptomatic 1year back and then he developed h/o intermittent chest pain and Sob ,and was diagnosed with diabetes and HTN 1 yr ago,on irregular medication and after that did not consult the doctor.
Came to our hospital last month with grade 4 SOB diagnosed with HFrEF,Renal failure with hypertension (?Cardiorenal) and
Dialysed in view of acute pulmonary edema 5 times last month,creat was 5.6
And then discharged on 2/6/2022
On Saturday patient presented again with c/o grade 4 SOB,fever-high grade since 5days.
c/o SOB (post dialysis day before yesterday pt felt better and again c/o SoB since today morning)
Fever spikes +
Known diabetic and htn on irregular medication.
General Examination:
Patient is c/c
Edema present,Bilateral pitting type of edema ,Till knees.
No pallor,icterus ,cyanosis,clubbing,koilonychia,lymphadenopathy.
No splinter hemorrhages,janeway lesions,osler nodes.
Patient is on NIV
Temp :102F
Bp: 140/100mmhg
PR : 110bpm
Spo2:80% at RA
96% with NIV
Cvs s1s2+,systolic murmur in tricuspid area,
Mitral area: continuous crepitation like sound which is increasing with inspiration?pericardial rub
Rs BAE+,B/L diffuse crepts
At admission
Creat:11.9
Urea:185
Hb:8.9
TLC:33200
Plt:4.89
Patient was dialysed on 11/06/2022(eveng),post dialysis urea:118,creat 8.4
Cultures sent ,report awaited
Started on inj piptaz
DIAGNOSIS:
SEPSIS 2to Infective endocarditis ( MRSA)
CKD on MHD
HTN since 1year
DM since 1 yr
HfrEF(all chambers dilated,ef 48%)
Discussion :
[6/13, 12:00 PM] Dr Chandana Gm Kam: Icu bed 4
30 year male
1year h/o intermittent chest pain and Sob ,was diagnosed with diabetes and HTN 1 yr ago,on irregular medication and after that did not consult the doctor.
Came to our hospital last month with grade 4 SOB diagnosed with HFrEF,Renal failure with hypertension (?Cardiorenal)
Dialysed in view of acute pulmonary edema 5 times last month,creat was 5.6
And then discharged on 2/6/2022
On Saturday patient presented again with c/o grade 4 SOB,fever-high grade since 5days
S:c/o SOB (post dialysis day before yesterday pt felt better and again c/o SoB since today morning)
Fever spikes +
O:O/E:pt c/c,on NIV
Temp :102F
Bp: 140/100mmhg
PR : 110bpm
Spo2:80% at RA
96% with NIV
Cvs s1s2+
Rs BAE+,B/L diffuse crepts
A:At admission
Creat:11.9
Urea:185
Hb:8.9
TLC:33200
Plt:4.89
Patient was dialysed on Saturday eveng,post dialysis urea:118,creat 8.4
Cultures sent ,report awaited
Started on inj piptaz
Echo showing mitral and tricuspic vegetations ( on 13th June )
Diagnosis:
CKD on MHD
HTN since 1year
DM since 1 yr
HfrEF(all chambers dilated,ef 48%)
? *Infective endocarditis*
Discussion:
[6/13, 12:10 PM] Dr Chandana Gm Kam: I can hear a systolic murmur in Tricuspid area
Mitral area: continuous crepitation like sound which is increasing with inspiration?pericardial rub
[6/13, 12:33 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Well done @Dr Chandana Gm Kam 👏👏
Present the findings in the afternoon session today also for our external examiner guests
[6/13, 1:19 PM] Dr K Vaishnavi Mam Gm Kam: Another case of infective endocarditis.( Another case to be added in hemodialysis associated infections)
Does our patient have central line ?
I can see vegetation on tricuspid valve . I'm not sure about mitral valve though .
Take 3 blood samples from different sites (one from cvp line) -20 ml each .
Repeat culture again after 24 hours .
Usually most common organism would be MRSA (cvp associated) .
Also chandana look for other manifestations like petechiae , fundus (Roth spots) , spinter hemorrhages ,osler nodes ,janeway lesions .
Also add vancomycin after drawing blood cultures along with piptaz
[6/13, 1:25 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Case report link made last month? @Dr Durga Krishna Gm Kam @Dr Pradeep Gm Kam
[6/13, 1:53 PM] Dr Chandana Gm Kam: Okay mam
The patient had central line ijv
Which came out on its own according to attendants when the patient is at home.
Now again femoral is placed for HD.
New femoral line
[6/13, 6:31 PM] saicharankulakarni: We have repeated cultures from central and peripheral iv line mam..
[6/13, 6:42 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Share the case report link also in the Microbology group and ask them to comment on the culture growth
[6/13, 8:57 PM] saicharankulakarni: Fundoscopy was done in view of Roth spots. But no fundus changes sir.
[6/15, 12:24 PM] Dr Rakesh Biswas Sir Hod Gm Kam: "HFmEF; 40% ≤EF <50%), the previously neglected “middle child of HF” (1), is increasingly receiving attention along with its famous older sibling, HF with reduced EF (HFrEF; EF <40%), and the favored baby of the HF family, HF with preserved EF (HFpEF; EF ≥50%)."
https://www.jacc.org/doi/10.1016/j.jchf.2016.03.025
[6/15, 1:12 PM] Dr Chandana Gm Kam: MRSA isolated
Review echo on 15/6
[6/16, 8:21 PM] saicharankulakarni: How many days has it been since this central line was placed ?
He has 2 central lines?
[6/16, 8:21 PM] saicharankulakarni: No mam previously 1 month before he was on Rt IJV after discharge he was late for routine follow up and he presented with Shortness of breath at rest with fever and displaced central line mam. In this admission we canulated Rt femoral mam.
[6/16, 8:21 PM] saicharankulakarni: It appears sensitive to clindamyicn too
[6/16, 8:23 PM] saicharankulakarni: https://venkatsaitodupunoori.blogspot.com/2022/06/ckd-on-mhd-this-is-online-e-log-book-to.html?m=1
In Breif bedside examination patient has difficulty in lifting right upper limb ( though swollen ) with deviation of mouth sir.
[6/16, 8:29 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Another stroke embolic. Post admission?
[6/16, 8:30 PM] saicharankulakarni: May be sir but more of proximal weakness than distal sir.
[6/16, 8:31 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Deviation of mouth?
[6/16, 8:45 PM] saicharankulakarni: Biceps, triceps, knee, ankle present sir. Plantars mute. However I have a doubt sir. As there is asymmetric UL edema, though both UL reflexes seems to be same. Is it exaggerated reflexes on Swollen limb sir currently he is facing difficulty in lifting up.
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