Concluded Case

PNEUMONIA WITH SEPSIS INDUCED AKI

66yrs/M presented with 3 days of dyspnea.Known Diabetic and Asthmatic on budesonide inhaler.He has never smoked.No H/o fever,dry cough or travel.COVID 19 ÑEGATIVE,LAB REPORTS ENCLOSED.ANY THOUGHTS?

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Concluded answer
Impression- Diabetes mellitus with Diabetic nephropathy with septicaemia with hyperkalemia with pulmonary embolism with respiratory failure associated respiratory acidosis with normal anion gap . Significant investigation findings 1.A very high D- Dimer level 3481 indicative of PULMONARY EMBOLISM or thtombosis associated with COVID-19 for which a nasp- pharyngeal swab for rt - RT - PCR needs to be repeated .Also LDH is significantly raised more than 600 favoring it 2.A high TLC - more than 15000 indicative of early septicaemia 3.A significantly raised S.Urea- 107 and S .creatinine 4.3 indicative of diabetic nephropathy or part of septicaemia 4.ABG studies indicate significantly decreased PO2 , acidosis , normal anion gap secondary to respiratory failure 5.X- ray chest - picture is that of ARDS with bilateral diffuse infiltrates seen in COVID-19 or CCF or pulmonary embolism or ILD 6.Hyperkalemia , anaemia . Further investigations needed are 1.A repeat Nasopharyngeal as well as oropharyngeal swab for COVID-19 disease 2.A HRCT or CT pulmonary angiography 3.A ventilation perfusion scan . Treatment- 1.Oxygen support with mask 2.Slow IV maintenance fluid only 3.parenteral antibiotics- inj Piperacillin 4 gm + tazobactum 500 mg × 8 hourly as these have renal safety. No aminoglycosides 4.Inj insulin in drip as per the blood glucose levels and calcium and bicarbonate if required to manage hyperkalemia 5.Monitoring of vitals , ABG levels , D- dimer levels , urine output, monitoring urea , creatinine, potassium, glucose levels
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Impression- Diabetes mellitus with Diabetic nephropathy with septicaemia with hyperkalemia with pulmonary embolism with respiratory failure associated respiratory acidosis with normal anion gap . Significant investigation findings 1.A very high D- Dimer level 3481 indicative of PULMONARY EMBOLISM or thtombosis associated with COVID-19 for which a nasp- pharyngeal swab for rt - RT - PCR needs to be repeated .Also LDH is significantly raised more than 600 favoring it 2.A high TLC - more than 15000 indicative of early septicaemia 3.A significantly raised S.Urea- 107 and S .creatinine 4.3 indicative of diabetic nephropathy or part of septicaemia 4.ABG studies indicate significantly decreased PO2 , acidosis , normal anion gap secondary to respiratory failure 5.X- ray chest - picture is that of ARDS with bilateral diffuse infiltrates seen in COVID-19 or CCF or pulmonary embolism or ILD 6.Hyperkalemia , anaemia . Further investigations needed are 1.A repeat Nasopharyngeal as well as oropharyngeal swab for COVID-19 disease 2.A HRCT or CT pulmonary angiography 3.A ventilation perfusion scan . Treatment- 1.Oxygen support with mask 2.Slow IV maintenance fluid only 3.parenteral antibiotics- inj Piperacillin 4 gm + tazobactum 500 mg × 8 hourly as these have renal safety. No aminoglycosides 4.Inj insulin in drip as per the blood glucose levels and calcium and bicarbonate if required to manage hyperkalemia 5.Monitoring of vitals , ABG levels , D- dimer levels , urine output, monitoring urea , creatinine, potassium, glucose levels
Valuable opinion
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Xray shows ground glass opacity high LDH, d dimer is very high, high serum creatinin, urea ,high HBA1c, high serum potassium all suggestive of covid19 with ARDS with multi organ failure.blood oxygen level is very low admit covid icu start oxygen and maintain oxygen saturation as per requirement,iv fluids to maintain hydration, antibiotic iv to prevent bacterial inf, ing methyl-prednisolon 40mg bd iv, LMWH 0.4 ml sc daily ,ing tocilizumab 3doses sos to prevent cytokine Strom ,anti viral Remdesevir or oral ravipiravir should also be started treat associated ds like COPD,diabetes, hyperkalaemia simultaneously and keep continuous watch on urine output and serum creatinine
Thank you doctor
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D-dimer is very high So as bul and sr creatinine Hemogram suggest leucocytosis With low hb Abg suggest respiratory alkalosis and hypoxic Xray chest suggest bilateral diffuse infiltrates Covid19 is negative It looks a c/o pulmonary thrombosis with leucocytosis
Thank you doctor
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Symptomatology in s immunocompromised patient, DD is PULMONARY KOCH, ASPERGILLOSIS, ATYPICAL PNEUMONIA, GIVE ANTIBIOTIC ESPECIALLY DOXYCYCLINE, GET BACK TO HISTORY AGAIN, WORK UP AS TB PROTOCOL BAL , BAL CULTURE TB PCR, ATYPICAL ORGANISM, gslactomannan.
Thank you doctor
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DIABETS..WITH..NEPHROPATHY.. LEUKOCYTOSIS.. ? ILD .. ? COVID-19.. NEED'S.. HRCT.. REPEAT.. RT..PCR..COVID-19..
Thank you doctor
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Please ask for repeat Swab test for COBID-19
Sir,Repeat also negative
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Bronchectesis with superadded infection
Antifungal Also may be added in treatment
? Pulmonary Tuberculosis
Treat as a covid patient
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