A 60-year-old male presented with multiple symptoms including shoulder pain, fever, chest pain, shortness of breath, and hematuria, alongside a history of uncontrolled diabetes and past shoulder trauma. Diagnostic workup suggested pulmonary embolism, complicated urinary tract infection, sepsis, and acute kidney injury. The patient received extensive medical treatment including antibiotics, steroids, and continuous monitoring in response to evolving clinical conditions and complications.

1. SEPTIC EMBOLI
Presentator:Dr.Devi sasi ram
Final year Resident
Moderator:Dr.Anjaneya prasad
Professor,HOD
Dept. of INTERNAL MEDICINE

2. CHIEF COMPLAINTS
A 60 year old man farmer by occupation came to ER with
• ℅ left shoulder and axillary pain since 1 month
• ℅ Fever for one day 7 days back
• ℅ Both Lower limb pain since 7 days
• c/o burning micturition since 3 days
• ℅ Chest pain and shortness of breath since 6 hours

3. History of present illness
• The patient was apparently normal one month back then
present complaint started as left shoulder and axillary pain
which is insidious in onset dull aching type radiating to entire
left upper limb.
• Aggravated since 7 days after massage , physiotherapy and local
injection (? Intra articular ) . Pain mainly aggravated with
abduction and was relieved to some extent on rest.

4. • Fever for one day 7 days back low grade not associated with
chills and rigors relieved with Antipyretic medication for one
day.
Pain in Both lower limbs since 7 days , Dragging type mainly in
the Thighs and calf region , aggravated on walking and not
relived with medication.
• H/o passage of red coloured urine for one day 3 days back
associated with burning micturition since 3 days.
Not associated with decreased urinary output
C/O Chest pain since 6 hours diffuse stabbing type, radiating to
both upper limbs, continuous, associated with palpitations.

5. • Shortness of Breath Grade-4 ,since 6 hrs sudden in onset ,No
aggravating and relieving factors not associated with cough
with expectoration, No postural variation
• No h/o Headache/Blurring of vision/ involuntary movements
• No h/o Abdominal pain/ vomitings/ loose stools/Dark coloured
stools

6. Past History
• H/o Trauma to the left arm 40 yrs back neglected and led
to Decreased ROM of left shoulder since the time of injury
• H/o NSAID usage since 1 month for shoulder pain
• K/C/O T2DM since 1 year on Inj. MIXTARD (30/70) 6 Units
8th hrly and on T. GLIMI M1 (1/500) half tablet 8th hrly,
not in regular follow up.
• Not a known case of
HTN/ CVD/CAD/COPD/TB/Epilepsy/CLD/CKD

7. Personal History
• Takes mixed diet
• Bowel habits – regular
• Bladder habits – Dysuria and hematuria +
• Appetite- Normal
• Sleep - Decreased
• Known Smoker since 12 years of age( 2 chuttas /day).
• Non alcoholic
Family History
• Nil significant

8. General Condition on Examination
• Patient is conscious, coherent and oriented
• Moderately built and moderately nourished
• No pallor/icterus/ cyanosis/clubbing/
• Pedal edema present- grade-1,pitting type, fast filling
Local examination of left shoulder :
• Tender diffuse Swelling present over the axilla upto 4th
intercostal space and also posteriorly up to lateral border
of scapula

10. VITALS:
• BP- 140/90 mmhg Right upper limb in supine position
• PR- 110 bpm Regular Rhythm & volume no Radio radial and
Radio femoral delay
• RR- 28/min abdomino thoracic type
• SP02- 94%RA , 98% with 2 lit O2
• Grbs-- 282 mg/dl

11. Systemic examination
CVS:
JVP not raised
S1,S2 heard no murmurs
Resp:
Bilateral normal vesicular breath sounds heard
Decreased breath sounds in Right infrascapular area

12. P/A
soft , Mild tenderness + all over the abdomen, No organomegaly
, BS +
CNS-
pupils - Bilateral NSRL
Power - ⅘ in all 4 limbs ,left shoulder can’t accessed
Plantars - Bilateral flexors

13. Provisional Diagnosis
• ? Acute coronary syndrome
? Pulmonary embolism
• Uncontrolled T2DM with Complicated UTI
• Left shoulder periarthritis

14. ECG

15. CXR:

16. • CARDIOLOGY referral I/V/O
• Acute onset of chest pain
and sob
BP - 110/90 mmhg
PR-95/min
ECG – sinus tacchycardia with
incomplete RBBB ( Rv strain)
O/E :
CVS- S1 and S2 present
RESP - B/l NVBS +
2D ECHO
• No LV RWMA
• Good LV Systolic Function
• Grade 1 DD
• No MR/TR/AR/PAH
• No PE/Clot/Vegetations
• IVC- Normal and collapsing

17. CBP Day 1
Hb 12.1
TWBC 15600
N/L/E/M 91/4/2/3/0
ESR 98
PCV 33.8
Platelets 150000
MCV 77.2
MCH 27.6
MCHC 35.7
RDW 14.1
LFT Day 1
T Bilirubin 4.3
D Bilirubin 3.6
I Bilirubin 0.7
ALP 302
SGOT 59
SGPT 61
T Proteins 5.1
Albumin 2.4
Globulin 2.7
A:G Ratio 0.8:1

18. RFT Day 1
S Urea 72
S Creat 1.3
S/E Day 1
Na 128(131)
K 4.4
Cl 94

19. ABG Day-1 After 12 hrs Day2
PH 7.40 7.41 7.38
PO2 82.6 86 80.4
PCO2 22.7 27 27.1
HCO3 17.1 17.6 17.5
Lactate 6.88 3.31 0.97
IMPRESSION Met.acidosis comp.
Resp Alkalosis
Lactic acidosis
Met.Acidosis comp.
Resp Alkalosis
Lactic acidosis
Metabolic acidosis
Comp.Resp alkalosis

20. Physical
Examination
Day 1
Volume 15.0
Colour Orange
Appearance Slight Cloudy
Chemical
Examination
Day 1
PH 5.5
Specific gravity 1.019
Protein Traces
Glucose + +
Ketone bodies Negative
Bilirubin Negative
Urobilinogen Normal
Blood Negative
Nitrite POSITIVE
Leukocytes +
RBC 1
Wbc 2
CUE:

21. SOBT
AMYLASE & LIPASE
LDH
D DIMER
Stool occult blood Negative

22. LEPTOSPIRA
WIDAL TEST
SCRUB TYPHUS
WIDAL TEST Day 1
S Typhi(O) 1:20
S Typhi(H) 1:20
S Paratyphi(AH) 1:20
S Paratyphi (BH) 1:20
SCRUB TYPHUS Day 1
Typhus IgG Non Reactive
Typhus IgG Non Reactive
LEPTOSPIRA ANTIBODIES Day 2
Leptospira IgM Non Reactive
Leptospira IgG Non Reactive

23. Usg abdomen and pelvis:
IMPRESSION :
** Hepatomegaly with Grade-I fatty changes.
**Mild altered echotexture of both kidneys - Correlate with
RFT's.
**Bilateral minimal pleural effusion.

24. PROVISIONAL DIAGNOSIS AFTER
INVESTIGATIONS
• PULMONARY EMBOLISM TO R/O DVT
• SEPSIS WITH MODS
• COMPLICATED UTI AND UNCONTROLLED T2DM
• AKI SECONDARY TO NSAID USAGE

25. Treatment
1. Inj . CEFTRIAXONE 1 g IV 12 th hrly
2. Inj. METROGYL 1g IV 24 th hrly
3. Inj. PANTOP 40mg IV 24 th hrly
4. Inj. HAI 0.5 ml/hr Infusion for 24 hrs overlaped with Basal
bolus regimen
5. Inj. TRAMADOL 50mg in 100ml NS SOS.
6. Inj. CLEXANE 0.6 ml s/c 12 th hrly
7. Vitals monitoring
8. Foleys catheterization

26. • Orthopedic opinion was taken i/v/o Left shoulder pain and
decreased ROM of left shoulder.
• On Examination-
Patient is examined in supine position with both ASIS at equal
level, both palms- facing roof on either side of body, both
patella- facing roof
Left shoulder and Cervical Spine
• C- spine – Diffuse tenderness present
• Apparent muscle wasting present over left arm
• Tender diffuse, paraspinal muscles present
• Tenderness elicited at Left shoulder/ proximal humerus
• No crepitus elicited
• Distal pulsations felt

27. ROM
• Abduction upto 40 degrees
• Internal rotation – 0- 20 degrees Of Left shoulder
Pelvis:
Tenderness elicited over both GT and SI joints
Adviced:
1. Xray of Left shoulder- AP , lat view
2. Xray of pelvis with both hips – Ap
3. T.ULTRACET SOS
Right Left
SLR 85 - 90 80-85
EHL +5/5 +5/5
FHL +5/5 +5/5
FABER Positive Positive
FADIR Positive Positive

30. On the next day, Patient developed sudden SOB- associated with
cough & sputum which is scanty, mucoid, non- foul smelling,
associated with hemoptysis- 2 episodes and Hypotension.
Vitals:
BP – 80/60 mmhg after 2 units Fluid bolus 90/70 mmhg
PR – 110bpm
Spo2 – 86%@ RA 92% @ 15 LIT O2
RR : 34 cpm
Adv:
Noradrenaline @5 mic/hr titrate according to BP
Cardiology, pulmonology opinion

31. • Pulmonology opinion was taken i/v/o sudden SOB and Hemoptysis
SPO2- 87%on RA, 97% with 35%fio2 on Bipap
O/E : associated with bilateral coarse inspiratory crepts in MA, IAA
Adviced:
1. Inj. DOXYCYCLINE 100mg 12 th hrly
2. NIV BIPAP if spo2- less than 85% and if Tachypnoea persists
3. T. TRANEXA 500mg 12 th hrly
4. Syp. GRILLINTUS –L 10ml 12 th hrly
5. Sputum for AFB, CB NAAT, G/S, C/S
6. ABG on RA

32. Cardiology opinion was taken iv/o sudden onset of SOB ?
Pulmonary Embolism which showed:
• Tachycardia during study
• No LV RWMA
• Good LV Systolic Function ( EF- 60%)
• Normal LV filling pattern
• No MR/AR/ TR/ PAH (RVSP- 20mmhg)
• No PE/ clot/ Vegetations
• IVC- Normal and collapsing
Added Inj. Dobutamine – 8ml/hr iv infusion due to low BP values.

33. CBP CBP Day 2 Day 4 Day 6 Day 7 Day 8 Day 10 Day 12 Day 13
Hb 8.9 9.4 9.2 9.5 9.8 8.4 8.3 8.3
TWBC 14830 18300 15810 17150 24400 15260 12850 11350
N/L/E/M 90/8/1/1/0 84/11/1/4/0 83/12/1/4/0 80/11/6/3/0 86/10/1/3/0 80/14/3/3/0 79/14/2/5/0 77/16/2/5/0
ESR 120 139 127 143 96 SNR 105
PCV 25.5 26.2 26.6 27.4 27.7 24.1 24.3 24.4
Platelets 150000 179000 191000 180000 285000 313000 342000 391000
MCV 79.5 76.0 78.5 79.2 76.9 80.6 80.6 81.8
MCH 27.7 27.3 27.2 27.4 27.2 28.1 27.5 27.8
MCHC 34.8 35.9 34.6 34.6 35.4 34.9 34.2 34.0
RDW 15 11.2 14 15 14.5 15 15 15

34. LFT LFT Day 2 Day 4 Day 6 Day 8 Day 9 Day 10 Day 13
T Bilirubin 6.1 9.1 9.5 8.8 9.4 7.1 4.7
D Bilirubin 5.1 7.7 8.1 7.5 7.8 6.0 3.8
I Bilirubin 1.0 1.4 1.4 1.3 1.6 1.1 0.9
ALP 259 483 606 607 553 646 584
SGOT 77 107 119 91 78 77 88
SGPT 52 47 52 49 42 45 57
T Proteins 4.8 5.9 6.1 6.5 7.6 7.5 7.0
Albumin 2.1 1.9 1.7 1.7 2.0 2.1 2.2
Globulin 2.7 4.0 4.4 4.8 5.6 5.5 4.8
A:G Ratio 0.7:1 0.4:1 0.3:1 0.3:1 0.3:1 0.3:1 0.4:1

35. RFT Day 2 Day 3 Day 4 Day 6 Day 7 Day 8 Day 9 Day10
S Urea 102 92 68 49 37 40 45 49
S Creat 1.7 1.5 1.2 1.0 0.7 0.9 0.7 0.7
S/E Day 2 Day 3 Day 4 Day 6 Day 7 Day 8 Day 9 Day 10 Day12
Na 135 134 135 136 135 134 134 135 132
K 4.5 4.3 4.5 4.6 4.9 4.7 4.7 4.7 4.8
Cl 103 100 102 103 104 102 103 104 102
Ca 7.5(9.1) 7.1(8.7)
Phosph
orus
4.3

36. Nephrology opinion was taken i/v/o Deranged RFT’s and
Metabolic acidosis
• Diagnosed as AKI secondary to sepsis, Pre- renal + Early ATN
PLAN:
1. Continue Hemodynamic supports
2. Fluids 1.5 to 2 lit/day
To do:
• Serum Uric acid, Calcium, Phosphorus

37. SERUM URIC ACID
SPOT URINE
Day 2 Day 8
Spot urine Chloride 72 91.7
Spot urine Sodium 44.6 127.2
Spot urine potassium 34.4 38.5

38. CREATINE KINASE
CRP
URINE MYOGLOBIN

39. CUE
Physical Examination Day 2 Day 3
Volume 20.0 25.0
Colour Orange Orange
Appearence Slight Cloudy Slight Cloudy
Chemical Examination Day 2 Day 3
PH 5.5 5.5
Specific gravity 1.016 1.016
Protein Traces Traces
Glucose Nil +
Ketone bodies Negative Negative
Bilirubin Negative Negative
Urobilinogen Normal Normal
Blood 2+ +
Nitrite Negative Negative
Leukocytes + +

40. BT & CT
PT & INR,aPTT

41. Gastro opinion was taken i/v/o Deranged LFTs
and drop in Hb
Adviced: Plain CT Abdomen i/v/o ? Dilated CBD
Ig M for Hep –A, Hep-E - was negative

42. URINE CULTURE
RESULT :Staphylococcus aureus(MRSA)(100000cfu/ml)
:Sensitive - Nitrofurantoin
ANTIMICROBIAL INTERPRETATION
Fosfomycin Sensitive
Gentamycin Sensitive
Norfloxacin Sensitive
Cotrimoxazole Sensitive
Pencillin Resistant
Erythromycin Intermediate
Clindamycin Sensitive
Amoxyclav Sensitive
Vancomycin Sensitive
Tetracycline Sensitive
Linezolid Sensitive

43. CULTURE-BLOOD
Name of the sample:Blood
RESULT :No bacterial growth after 48 hrs of aerobic incubation
Sputum : Negative for AFB,
Gram positive cocci in chains clusturs
Sputum c/s - staph aureus(MSSA)
ANTIMICROBIAL INTERPRETATION
Gentamycin Sensitive
Cotrimoxazole Sensitive
Pencillin Resistant
Erythromycin Sensitive
Clindamycin Sensitive
Amoxyclav Sensitive
Vancomycin Sensitive
Tetracycline Sensitive
Levofloxacin Sensitive

44. • Fever spikes were noted on
Day 3- 100F
Day 4- 2 fever spikes
Added
1. Inj. LINEZOLID 600mg 12 th hrly
Fundus Examination : No signs of Retinopathy

45. X ray D3

46. ABG Day-3 Day5 Day9
PH 7.39 7.432 7.48
PO2 76.2 87.6 80.4
PCO2 31.8 30.8 15.5
HCO3 20.4 21.6 15.9
Lactate 2.75 1.97 1.64
P/F 168 241 400
IMPRESSION Met.acidosis comp.
Resp Alkalosis
Lactic acidosis
Mod ARDS
Resp Alkalosis
Mild ARDS
Metabolic acidosis
Comp.Resp alkalosis

47. • Pulmonology review was done i/v/o
CHEST x ray shows- Bilateral non- homogeneous opacities- ? Bilateral
Consolidation
Impression: Bilateral Pneumonia with Sepsis with MODS with Type-
1RF
Adviced:
1. With hold Inj. CEFTRIAXONE
2. To add Inj. MEROPENAM 500mg 12 th hrly
3. Inj .HYDROCORTISONE 100mg 8 th hrly
4. Nebulization with Foracort 12 th hrly

48. CT CHEST:

50. Ct chest
• Multiple varying size cavitatory lesions along with areas of
consolidation involving both lungs
• Left subscapular and Deltoid abcess , sclerosis of humerus
head
S/o
• Multiple septic emboli i/v/o abscess in the left shoulder
D/D:
• Cavitatory metastasis
• Vasculitis are less likely
Fibrotic strands and interstitial thickening seen involving both
the lungs - represent sequelae of prior infection

51. Usg of left Axilla:
• Irregular hypoechoic area measuring 6.0 x 2.3 cm noted in the
intramuscular plane in the deltoid muscle on left side. No
significant adjacent vascularity noted.
• Discontinuity of the muscle fibres noted.
Possibilities include -
1) Intramuscular abscess.
2) If any history of trauma other possibility include partial tear in
left deltoid muscle with hematoma.

52. General Surgery opinion was taken i/v/o ? Left shoulder abscess
On examination:
• Ill defined swelling of approximately 3×2cm with surrounding skin
induration noted over the posterior aspect of left proximal arm
with local rise of temperature
• USG of swelling suggestive of Intramuscular Abscess
• Local Aspiration of Abscess done under SAP and yielded a pus of
0.2cc

53. • USG guided aspiration of Intramuscular Abscess drainage
done , no aspirate noted due to Thick pus
Ortho review was done i/v/o CT scan showing sclerosis of
humerus head and advised
1. Shoulder mobilization exercises
2. Ice Pack application

54. 2D ECHO REVIEW : day 10
• No LV RWMA
• Good LV Systolic Function EF -60%
• LVID (d)/(s) = 4.3/2.9 cm
• IVS(d)/PW(d) = 1.1/1.15 cm
• Grade 1 DD
• No MR/TR/AR/PAH RVSP-20 mmhg
• No PE/Clot/Vegetations
• IVC- Normal and collapsing

55. • Again fever spikes noted on DAY -6,7,8,10
• General Surgery review was taken i/v/o Abdominal tenderness
persistent, Direct hyperbilirubinemia and Therapeutic Drainage of
subscapular and Deltoid abscess
adviced
• CECT Abdomen or MRCP to R/O cholangitis
• Plan I&D for abscess

57. Abscess culture and sensitivity
STAPHYLOCOCCUS AUREUS
(MSSA)
ANTIMICROBIAL INTERPRETATION
Cephalothin Sensitive
Gentamicin Sensitive
Ceftriaxone Sensitive
Cotrimoxazole Sensitive
Pencillin Resistant
Erythromycin Sensitive
Clindamycin Sensitive
Amoxyclav Sensitive
Vancomycin Sensitive
Linezolid Sensitive
Levofloxacin Sensitive

58. Venous Doppler of left upper limb
• Axillary vein thrombosis with significant
flow restriction
Patient was Discharged with stable vitals
and was in surgery follow up for regular
dressings

59. Final Diagnosis
Sepsis with MODS - Staphylococcal septicaemia secondary to
left subscapularis and Deltoid abscess
Left Axillary vein thrombosis
Complicated UTI (Recovered)
Pre Renal AKI (Recovered)
Moderate ARDS ( Recovered)
K/c/o Type 2 Diabetes Mellitus

60. THANK YOU