Transcription
[Music] A 30-year-old male presented to the ER with complaints of fever since one week, loose stools, and generalized tiredness since four days. On initial 10-second assessment, the airway is patent; no pooling of secretions. Breathing: respiratory rate is 16 per minute; saturation 99% on room air; air entry bilaterally equal. Circulation: BP is 110/70 mm of mercury; pulse rate is 86 per minute; all peripheral pulsations are equally felt. Disability: GCS 15/15; bilateral pupils equal and reacting to light. Exposure: temperature is 100.6 degrees Fahrenheit; GRBS was 100 mg per day. We have given an injection of PCM 1 g IV stat. At this point, adjunct to primary survey, we had done a CBC, CRP point of care showing WBC count of 3,800; hemoglobin 10.4; and platelets of 96,000; and CRP of 88; and VBG showing pH of 7.44; potassium 3.4; sodium 125. What is the WBC count? 3,800. Okay, what are the bacterial infections will have normal WBC count? Salmonella Typhoid is the only known infection in our area which can produce a normal count. Leptospirosis sometimes can have this, but the most common infection in our area with normal WBC or slightly low WBC is Typhoid. Chloride of 92; lactate 1.3; creatinine 1.19; and bicarbonate of 23.9.
Coming to secondary survey: A 30-year-old male with no known comorbidities presented to the ER with complaints of fever since one week. Fever was mild initially, subsiding on antibiotics, and then recurred. The patient also had complaints of loose stools, 7 to 8 episodes per day since the last four days. What are the fever episodes associated with loose stools? Fever conditions: common infections; enteric fever; and which type of enteric fever? Paratyphoid. Then common infections in our area which are associated with diarrhea are typhoid, then H. pylori bacterial gastritis, etc. All these things, then amebiasis. Normally, there is a different category of infection; they may not have a high-degree fever; they can have fever, but this type of fever is not very common. Then hepatitis; hepatitis A is very common in our area. Okay, dengue is one condition where you can get diarrhea; many patients with dengue are having diarrhea. Um, the patient also had complaints of loose stools, 7 to 8 episodes per day since the last four days. No history of blood in stools. Uh, he also had what? The electrolyte abnormalities you see in diarrhea? ABG abnormalities: carbonates can be lost; pot, chloride; hyponatremia. Is potassium low in diarrhea? It is not very common. Severe diarrhea like cholera and all, you can get routinely potassium loss. It is less in diarrhea than vomiting. Okay, okay. Uh, he also had complaints of generalized mild abdominal pain, which was dull, aching, and non-radiating type. There were no aggravating or relieving factors. There is no history of any cough, shortness of breath, dysuria, rash, or blood in stools. No rashes or altered behavior. Uh, uh, he was evaluated outside, and Widal was done from outside, which showed… You are asking about altered behavior in this patient. Diarrhea patient, NRI, and Kaopectate. Okay, then only ENT. Electrolytes: which electrolyte imbalance can produce altered behavior in diarrhea? Is it common? You're seeing a lot of diarrhea. It is not very common as such; it will not produce electrolyte imbalance and that produces encephalopathy is very, very rare. Toxic encephalopathy can occur sometimes. A patient who is having chronic liver disease can have some type of altered behavior; otherwise, diarrhea as such will not produce any type of encephalopathy. Atypical pneumonia: diarrhea is very, very minimal, not like this. They have loose stools, but they will not have this type of diarrhea. He was evaluated outside and Widal was done from outside, showing Salmonella O more than 640, and Paratyphoid H and DH are less than 80. What is the difference between O and H? Um, which is more important in remote infection here? Which one is positive? H is positive, so we cannot completely depend on this investigation. So what do you do to diagnose it? Blood cultures. One is blood culture; the second thing, can you do another investigation of Widal? So if there is an increase in the titers of O titer, then it is diagnostic; or a sudden surge of the titer within 48 hours to fourfold or sixfold, then that is also diagnostic. Here, it is only H positive. Okay. On examination, the patient is conscious, oriented, and obeying commands. What is an anamnestic reaction? O, H, I mean, an anamnestic reaction is more common in which, O or H? H. H. So, some other infection producing itis or previous infection producing itis. Okay. Um, there is no pallor, clubbing, or lymphadenopathy. Per abdomen soft, non-tender; bowel sounds were present. Uh, respiratory system normal; vesicular breath sounds; no added sounds. The patient is complaining about abdominal pain. What investigation would you do? Ultrasound abdomen. Hospital is very important. Ultrasound can be done. Erect abdomen x-ray is the most important investigation which can be done in the ER. You can do a CT scan if available, but erect abdomen x-ray is one of the most important investigations in this case. Why is it like that? To rule out perforation. Perforation. Gas under diaphragm. Okay, they will not produce; they will not have intestinal obstruction; they have indal perforation. Okay. Um, CVS: S1 S2 normally heard; no murmur. CNS: no focal neurological deficits. We had done a blood investigation. What are the CNS abnormalities of typhoid? Ming, what is it? Picking clothes. Okay, so that is a most important and most early finding of encephalopathy. Um, Ming, delirium. Del… Blood investigations showing a total count of 4,000, and zero isospores. Can you get high, high WBC count in enteric fever when there is peritonitis? Peritonitis. Okay. Uh, UA was 20.5; creatinine 1.7; and SGOT was 90. Is creatinine normal here for this age? Slightly high. Slightly high. So, what are the reasons for this? Enteric fever as such will not produce elevation in creatinine. Most of the cases, if you see follow-up cases, you don't see much elevation of creatinine in patients. What may be the reason here? Dehydration is the most important cause which can produce… So how do you know that it is dehydration? UA; UA may be very high. Then other features are clinically dehydration. Then, VBG. VBG, what you're looking at? Lactate is higher; no, lactate was 1.3. 1.3, slightly higher, but it is normal. Sodium: sodium 125. Okay, that is also low. Okay. Can it happen like that? The dehydrated patient sodium can be low. Hyponatremia, hypotonic hyponatremia. The patient is not taking salt; losing a lot of salt; both can. Okay. Um, and uh, SD was 90; SGPT 56.6; and alkaline phosphatase was 95. Um, lab sodium was 24.8 and potassium 3.5, and CRP was 177 on the day of admission. Okay. You see, ALT is higher than SGPT. Is it very common in infections? ALT higher than SGPT? Normally, in infectious hepatitis, what is usual? What you have seen? SGPT is always higher than ALT, but patients who are taking alcohol, ALT will be slightly higher than SGPT. Why is it like that? ALT is elevated; it is not ALT elevated; SGPT is not produced; that is a reason. Then alcohol can reduce the production of SGPT; that is a reason. Okay. You have to ask the history of alcohol in this patient. We had done a USD abdomen and pelvis, which showed borderline splenomegaly, and uh, blood culture was positive from gram-negative bacilli, and he had fever spikes and loose stools during the course of… What is procalcitonin? Procalcitonin was uh, 50. 50. 50. Uh, then the patient was started on piperacillin, and now the patient is not having any fever spikes or loose stools, and we given symptomatic management for loose stools and IV fluids, 30 ml per kg. Mhm. What is your loperamide? What is the action of that drug? Anticholinergic. Anticholinergic. En… En… Enteis. Enteis. Okay, reduction in the gastric secretion. Can you give loperamide in this patient? No. Can… Can… If there is no… There will be collection, and it can be… Collection means what? Huh. Toxic megacolon means what? What is that? When you use this type of drugs, the patient can have stasis of your stool, which can be there in the intestine; that can sometimes produce more infection, more absorption; then the intestine can get dilated, so that should be avoided. You should never give loperamide or Lomotil in infective diarrhea. Other types of diarrheas, you can give. Okay. Now, the patient's symptomatic plan for discharge. Where will you use steroids in enteric fever? Um, there is… What is the dose of steroid? 3 mg per kg. 3 mg per kg per kg. So it will become how much? Which steroid you give? Dexamethasone. What… How it is different from hydrocortisone? Dexamethasone. Why you prefer dexamethasone in enteric analitis? Why can we give hydrocortisone? Yes or no? Yes or no. Can you give hydrocortisone in enteric analitis or common meningitis? Meningitis also, we give. First, do we give dexamethasone in encapsulated organisms? Why is it like that? What is the advantage of dexamethasone over hydrocortisone? It crosses the blood-brain barrier. That is the answer. It crosses the blood-brain barrier. This is one of the most important drugs, steroids, which crosses the blood-brain barrier, so we give in all types of neurological conditions. We give dexamethasone. Is there any advantage over hydrocortisone in enteric meningitis? Is it mineralocorticoid action there or not? It is less comparing with hydrocortisone. You give hydrocortisone or… Myalgia; fluid retention is more. Okay. In analitis, meningitis, we don't want further fluid accumulation, so we don't try all these things. Dexamethasone is cheap and best, and it crosses the blood-brain barrier. There is no fluid retention; there are a lot of advantages; there is no major disadvantage. Okay. Which condition is hydrocortisone better than dexamethasone? Sepsis. Sepsis with shock. In shock conditions, where the shock is associated, then hydrocortisone or methylprednisolone will be a better choice than dexamethasone. That also got some mineralocorticoid action, but not like other drugs. Okay. Now, what happened to this patient? Antibiotic: you continued antibiotic or de-escalated it? It is de-escalated. What is de-escalation? De-escalation and escalation means what in antibiotics? What is that? Recent septic sepsis bundle guidelines: we have to start antimicrobial antibiotic in one hour. First one hour. So it is not always true that you are starting antibiotic and continue that antibiotic continuously for many days. You can de-escalate. Suppose you find out that this infection is susceptible to a low antibiotic, you can de-escalate, or sometimes you escalate. Okay. So here we are de-escalated. Side reaction. Is there any difference between meropenem and piperacillin? Is there any difference between these two? Should we de-escalate this antibiotic? Yes or no? Since you already de-escalated, I am not telling anything, but is there any difference? There is no difference; there is no need to de-escalate because both are in the same category; you don't need to de-escalate it at all. Okay. So you can continue the drug same like that. How long you have to continue? 10 days. 10 days. 7 days is enough; most of the enteric fevers will subside within 7 days. Some patients may require longer treatment. What type of… What subset of patients? Carriers. Carrier. What type of profession? Cook. Chef. Chefs, they require maybe longer treatment; they require follow-up. How do you follow up? Stool culture. Stool culture. Okay. Suppose stool culture is positive and is asymptomatic, what do you do? Okay. Ciprofloxacin. Why ciprofloxacin? You can give ciprofloxacin. Why isoxazolyl? You all completed NEET and came here; that's why I'm asking this question. From where this bacteria is, where it is harboring, and where it is coming out? Gallbladder. Gallbladder. Which is the drug which has got high concentration in the gallbladder, better than your ciprofloxacin? They have got high concentration there; that's why you can use it as prophylaxis. Okay. What happened to this patient? Is he having any enteric canopy? Peritonitis? Any other complication he developed or now he says symptomatic? No. Okay. Is Salmonella resistant? Enteric fever can be resistant? No. It is a resistant-sensitive, so you can de-escalate to ciprofloxacin also. That is the most important drug which can prevent further episodes. Okay. Now, what happened to send Widal titer? Why repeat came as within… Okay, that culture is enough. Okay. Thank you. [Music]