Location :3B

SB Dr Goh CB, Dr Rishen

52yo/Malay gentleman
allergy to cloxacillin- will develop rashes the whole body
Active smoker - 1 pack/day

Underlying
1) DM x5yrs
- on Metformin and Daonil
- under KK Larkin
2) PVD - done left lower limb bypass x 2
3) Diabetic nephropathy

Home medications :
SC Mixtard 22/20
T. Meformin 500mg BD
T. Perindopril 4mg OD
T. Simvastatin 40mg ON

Revised Impression (23/1):

1/ Gram +ve cocci bacteremia 2' pneumonia ( probable strep. pneumoniae )
2/ Resolved Septic shock secondary to partially treated pneumonia
3/ TRO CKD ( diabetic nephropathy)
4/ UL DM/PVD/ Left charcot foot

Chief Complaint :
Fever and vomiting

Current Complaint :
persistent fever for 3 days,not resolved after taking PCM
previously had Fever on and off x 1 year, resolved by taking PCM
A/w chills and rigors, no night sweats

worsening cough 3/7

had on and off cough for 1 year
whitish sputum, no blood stained
Went to KK multiple times, treated with EES
last EES taken 2 weeks ago- completed abx as suggested
TB workup done end of 2016 - negative
No LOW/LOA

C/o left sided pleuritic chest pain past 3-4 days

Pain on breathing in only
Non radiating, not a/w diaphoresis
Vomitted 3-4x/day past 2 days
Fluid, non billous, no blood

Otherwise,
No abdo pain
No diarrhoea
No UTI sx
No nausea/ vomiting

Wound over plantar aspect of medial left foot bleeding occasionally

No pus discharge

Personal history
married, staying with wife and 3 children
pensioner
previously work at Oil and gas company in Terengganu
active smoker
30packyear
denied high risk behaviour

Progress:
Comfortable under RA
No desatuerations

Afebrile
BP ranging from 115-158/66-97 mmHg
0n IV ceftriaxone 2g OD - D3
On IV Azithromycin 500mg OD - D2
CRP : 469
Blood CS : g. +ve cocci

GM 8.8-16.1
SC Actrapid 6IU PRN if GM >12

I/O : 1802/1600 (+202)

On IVD 2pint NS

Ambulating well in ward

Otherwise,
No SOB
No chest pain
No vomitting

No desaturation
Examination :
Alert
GCS full
Oriented to place person and time
Hydration fair
Coated tongue
JVP not raised
No hepatopslenomegally

VS
T 37
R 20
P 88
BP 139/ 76 mmHg
SPO2 97% under RA

Lungs bilateral clear air entry, no occasional ronchi

CVS DRNM
PA soft, non tender, no guarding, no hepatosplenomegally

Left lower limb:

dry wound over medial aspect of plantar aspect of left foot
no pus discharge, no bleeding

Investigation :
FBC minilab 21/1
WCC 24.3 26.5
Hb 14.8 13
PLT 210 283

CRP :469

RP 21/1 22/1
Na 126 134
K 3.7 3.2
Ur 7.4 10.1
Cr 222 164

Mycoplasma : +ve 1:80

CXR bilateral haziness, borderline cardiomegaly

ECG SR, no acute ischemic changes

Urine dipstick: prot 3+, glu 2+, bld 1+, ket nil, leu & nit nil

Bedside USG:
IVC 1.8cm

Treatment at ED :
IV Unasyn 3g stat
T. PCM 1g stat
IVD 2 pint NS

Plan :
V/s monitoring
Keep spo2> 95%
GM BD

Repeat FBC, RP cm
Off IVD

Start SC Actrapid 6IU TDS,

SC Insulatard 8IU ON

Cont IV ceftriaxone 2g OD - to complete for 10days

IV Azithromycin 500mg OD - to infuse over 2H
SC Actrapid 6IU PRN if GM >12
IV maxolon 10mg PRN
T.slow K 1.2g BD for 3 days ( KIV off tomorrow)

Trace blood C+S sent in ED

Daily dressing on left foot DFU

withold home meds for now