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60 year-old man, with history of smoking for the last 30 years & known diabetic presented with c/o fever, cough

• 60 year-old man, with history of smoking for the last 30 years & known diabetic presented with c/o fever, cough with yellow sputum & shortness of breath for last 6 days and h/o irrelevant speech and drowsiness for one day.
• The patient has not passed urine for the last 18 hours. O/E Temp. 102°F, pulse of 112/min and BP 90/60 mmHg and mildly icteric and has petechial eruptions over the shin bilaterally.
• On chest examination there is bronchial breathing with crackles in right lower chest from 5th intercostal space downwards. Pt. is drowsy and not oriented in time, place & person.

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His lung findings could indicate  pneumonia/empyema. His confusion is related to severe sepsis causing encephalopathy or related to uremic encephalopathy if he also has renal failure due to ATN. He might be in DKA also as sepsis can trigger it in this diabetic patient.

We know  that sepsis can affect any organ causing multi-organ failure

This gentle man is in septic shock (low BP, tachycardic, altered mental status), needs emergent evaluation of his resp. status and assess for emergent intubation.

Likely Diagnosis:

 Complicated Pneumonia with or with out empyema leading to sepsis (bacteremia, sepsis, causing possible DIC)-

Evaluation:

order blood cultures, sputum cx, urine culture, CXR/CT chest, ABG, U/A, anian gap, blood sugar, ketones, serum Lactic acid, UCX, creatinine

therapy:

-start IVF bolus with NS 1-3 L, then reassess for need for  vasopressors like dopamine/levophed

-start broad spectrum antibiotics like vancomycin and pipercillin/tazo 

- airway management: emergent intubation to protect airway

-he will have some evidence of DIC due to sepsis, so monitor for bleeding

-control his blood sugars with insulin and IVF

Source control is important, so order CXR/CT chest to localize the source.

Dr.Singh, I did not get your point completely. I am sorry if I am interpreting your comment incorrectly.

You mentioned that there is no need of testing, so  would you blindly start him on some antibiotics with out doing some studies to find out the source and type of organism he got? How are you going to assess the duration of the antibiotics and if patient is getting right antibiotic or not? You might say, yes we can assess by looking at the patient, that is a posssibility, but if the patient is too sick in ICU, would  you wait until he shows himself that he is looking better? I would not.

You also mentioned that " it is clearly understood that he has taken modern medicines for a very long time to keep his diabetes under control and due to prolanged use of these medicines, the side effects could be seen".

Could you eloborate more of this statement? how do you know what he is taking? what is the evidence that his modern medication usage caused his current pneumonia/septic shock???

am I missing some thing here??

How would you manage Diabetets? I do not know much about herbal meds but I would be scared to death to take or advise taking just herbal meds alone for diabetes (no offense to herbal products). What are the long term effects of modern allopathic diabetic medications? Tell us your experience Dr.Singh.

 

You mentioned that you could use the money to buy good hernbal medications. Hmm, I guess you are practicing herbal medicine, that is good, but I do not hink herbal medications are going to work for this patient in this current critical illnes.

The tests I recommened are all has a reason and benefit of doing. I practice medicine in USA and I do practice cost-effective medicine, but not at the expense of missing the diagnosis or treatimng with a gut feeling or putting patient's life at risk.

There has been extensive research done in area of sepsis and there are great guidelines for sepsis put forward by different infecious disease societies. Following the guidelines and managing the patient with early goal directed therapy, source control has yeileded great results.

tests:

Culutres, CXR/CT chest- to identify the organism to tailor the antibiotic type/duration, scans to localize the source and to see if he needs any drainage of any empeyme or abscess.

Anian gap, sugar, creatinine, ketones- to see if he is in DKA (diabetic ketoacidosis), poorly controlled blood sugars during sepsis yeilede dpoor outcomes in various studies.So syrict blood glucose control with iv insulin is recommended in sespis

lactic acid- will tell us the tissue hypoxia, then the severity of sepsis

 

I love to know more about herbal medicine. But I would really appreciate if you could explain the  rationale behind your comments . Thank you doctor for sharing your thoughts.

 

My comments may look defensive, but my intention is to share my thoughts about evidence based medicine and to encourage my collegues/medical students to practice evidence based medicine and to think systematically when seeing a patient rather than jumping on to conclusions based on the gut feeling. I hope I would  interest some of the practicing physicians and medical students in India.

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