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Suggest Treatment For Fever, Abdominal Pain, Nausea, Right Leg Pain And Swelling
Question: Dear Dr.
I am Dr. XXXXXXX working in an insurance company. I would like to have a second opinion on one of my patient.
Presenting complaints:
A 53 years old male patient presented with complains of fever, abdominal pain, nausea and right leg pain and swelling.
HOPI:
He presented with history of fever and abdominal pain associated with nausea for 2 days. He presented in the emergency when he acutely developed pain, swelling and redness in the right leg. He was unable to walk and came to the hospital in a wheel chair.
Vitals at time of admission: 106 beats/min, 120/80 mmHg, 36.7 0C, 98% on room air.
Laboratory Investigations at admission:
WBC: 23.5
CRP: 303.9
D-Dimer: 0.62 (slightly raised)
Glycosylated Hb: 7.2 (raised)
Procalcitonin: 6.55 (raised)
Diagnosis:
Cellulitis.
Course of Hospitalization:
He was admitted in the hospital, DVT was ruled out and was started on Meropenem and Augmentin (after he had received one dose of Rocephin and Augmentin in emergency) along with antipyretics and analgesics, to which he responded and became afebrile.
On third day of admission he had a spike of mild fever but was subsided with IV paracetamol. His investigations showed down going trend of inflammatory markers as: WBC: 13.1, CRP: 211(decreased than previous)
During rest of his admission he was kept on the same treatment and started walking on fourth day of admission without pain.
I have attached the leg girth chart for your kind reference also.
I am concerned about the choice of antibiotics in this case as coverage of meropenem and Augmentin is mainly gram +ve. The same query was raised to the treating doctor who replied that usually the cellulitis in such patients is due to streptococcus and meropenem was added for coverage of anaerobes.
Kindly give me your expert opinion if the choice of antibiotics was appropriate in this case and please also refer me guidelines on the basis of which you think the choice of antibiotics was right.
I am Dr. XXXXXXX working in an insurance company. I would like to have a second opinion on one of my patient.
Presenting complaints:
A 53 years old male patient presented with complains of fever, abdominal pain, nausea and right leg pain and swelling.
HOPI:
He presented with history of fever and abdominal pain associated with nausea for 2 days. He presented in the emergency when he acutely developed pain, swelling and redness in the right leg. He was unable to walk and came to the hospital in a wheel chair.
Vitals at time of admission: 106 beats/min, 120/80 mmHg, 36.7 0C, 98% on room air.
Laboratory Investigations at admission:
WBC: 23.5
CRP: 303.9
D-Dimer: 0.62 (slightly raised)
Glycosylated Hb: 7.2 (raised)
Procalcitonin: 6.55 (raised)
Diagnosis:
Cellulitis.
Course of Hospitalization:
He was admitted in the hospital, DVT was ruled out and was started on Meropenem and Augmentin (after he had received one dose of Rocephin and Augmentin in emergency) along with antipyretics and analgesics, to which he responded and became afebrile.
On third day of admission he had a spike of mild fever but was subsided with IV paracetamol. His investigations showed down going trend of inflammatory markers as: WBC: 13.1, CRP: 211(decreased than previous)
During rest of his admission he was kept on the same treatment and started walking on fourth day of admission without pain.
I have attached the leg girth chart for your kind reference also.
I am concerned about the choice of antibiotics in this case as coverage of meropenem and Augmentin is mainly gram +ve. The same query was raised to the treating doctor who replied that usually the cellulitis in such patients is due to streptococcus and meropenem was added for coverage of anaerobes.
Kindly give me your expert opinion if the choice of antibiotics was appropriate in this case and please also refer me guidelines on the basis of which you think the choice of antibiotics was right.
Brief Answer:
hit hard and hit fast in sepsis
Detailed Answer:
Hi XXXX
Welcome to healthcare magic.
Your patient was shifted to ER in nearly stable hemodynamics that meant not much cardiac issues. But he had Tachycardia and Raised TLC to suggest SIRS.
His leg had swelling and there was pain abdomen. CRP and procalcitonin are alarmingly high.
The doctor is right in choosing a well prescribed policy of Hit hard and Hit fast, with broad spectrum antibiotics. Delaying in such cases may lead to severe sepsis or MODS which carry high mortality.
There is a choice for deescalation of treatment if there grows a susceptible organism or after the problem subsides reasonably.
I hope the advise will be helpful for you.
hit hard and hit fast in sepsis
Detailed Answer:
Hi XXXX
Welcome to healthcare magic.
Your patient was shifted to ER in nearly stable hemodynamics that meant not much cardiac issues. But he had Tachycardia and Raised TLC to suggest SIRS.
His leg had swelling and there was pain abdomen. CRP and procalcitonin are alarmingly high.
The doctor is right in choosing a well prescribed policy of Hit hard and Hit fast, with broad spectrum antibiotics. Delaying in such cases may lead to severe sepsis or MODS which carry high mortality.
There is a choice for deescalation of treatment if there grows a susceptible organism or after the problem subsides reasonably.
I hope the advise will be helpful for you.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear Dr. Choudhary, Thank you for your reply. I agree with your opinion for starting broad spectrum as Meropenem, but I have not found any guideline that supports this choice of antibiotics. It would be a great help, if you can refer to an international guideline that supports this antibiotic regime in the above mentioned scenario.
I will be much obliged for your help.
I will be much obliged for your help.
Brief Answer:
regime depend on local resistance pattern
Detailed Answer:
Hi
Welcome back.
Guidelines do not name antibiotics actually.
They advise broad spectrum antibiotics initially and then deescalate as per culture and sensitivity reports. In serious cases the treating doctor should decide the choice and regimen of antibiotics depending upon the institutional antibiogram and resistance pattern and prevalence of cases in the particular region.
I hope the advise will be helpful for you.
regime depend on local resistance pattern
Detailed Answer:
Hi
Welcome back.
Guidelines do not name antibiotics actually.
They advise broad spectrum antibiotics initially and then deescalate as per culture and sensitivity reports. In serious cases the treating doctor should decide the choice and regimen of antibiotics depending upon the institutional antibiogram and resistance pattern and prevalence of cases in the particular region.
I hope the advise will be helpful for you.
Note: For more detailed guidance, please consult an Internal Medicine Specialist, with your latest reports. Click here..
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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