A.T. is a 15 y/o AA Female, Full code, NKA Admitted on 10/7 for acute generalized weakness, abdominal pain, vomiting, diarrhea, fever, presented with septic shock requiring vasopressor support, found to have Group A strep, toxic shock now presenting with fever
She was last in the E.D 2 days ago and given cefepime and metronidazole
Pt complains of diarrhea but has improved since. Abdomen is slightly distended, painful and hurts when moving. Patient can tolerate food and fluids fine. Her breathing was less labored, Diminished lung sounds in the lower bases of the lungs, urine is dark in color, +2 non pitting edema in lower extremities.
Internal jugular was placed which resulted in thrombosis
Patient presented tachycardia with PVC mitral valve regurgitation, 10 kg weight loss
Bilateral pleural fusion, Lasix was given to the patient
Vitals: BP: 109/56 HR: 89 SpO2: 97% RR:16
Medications
Tylenol 650 mg
Cefepime 40mg
Vitamin D3 5000 units
Dicyclomine capsule 10 mg
Enoxaparin 300 mg/3 ml
Famotidine tablet 20 mg
Granisetron HCL 1mg/ml
Ibuprofen 400 mg tablet
Flagyl 5mg/ml
Multivitamin
Breeza oral liquid 500 ml
Labs
WBC 16.46
RBC 2.63
Hemoglobin 7.9
Hematocrit 24.1
Platelets 1,028
Creatinine 0.4
C-reactive protein 13.7
Neurological – GCS 15, Alert and oriented x 4. CN 2-12 intact. Sensation to light touch and cold stimuli intact bilaterally
Musculoskeletal – Normal power was 5+ grip and elbow, knee, and ankle flexion and extension bilaterally. Patient is able to walk without difficulty
Respiratory –, regular respirations, diminished breath sounds in the lower lobes
Cardiovascular – +2 edema present in lower extremities , < 3 seconds capillary refill, Normal S1, S2 present
Integumentary – Normal color for ethnicity, skin is warm, dry, intact,
Gastrointestinal – Last BM 10/6, slightly distended, soft, tender abdomen, normoactive bowel sounds present in all 4 quadrants Genitourinary –dark colored urine
Patient was ordered a CT Scan, Chest X Ray , Daily Weights, Daily Measurement of Abdominal Girth, CT Bilateral Pleural effusion
