KVIJAY KUMAR 92

​This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of  " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

       A 75 year old male  came to casualty with chief complaints 

  Fever since 2 days , ALTERED SENSORIUM SINCE today

History of SHORTNESS OF BREATH SINCE 2 DAYS.

HISTORY OF DRY COUGH on and off SINCE 8 months

HISTORY OF PRESENTING ILLNESS:

      Patient was apparently  asymptomatic 1 year back and then started refusing to sleep in his room after the demise of his wife patient had c/o decreased hearing on his left ear brought for consultation and diagnosed to be having HTN and was prescribed on ANTI HYPERTENSIVE DRUGS (on irregular medication)  then he had multiple episodes of DRY COUGHsince 8 months 

he had FEVER which has been associated with chills and rigor on and off since 8 month 3 episodes

H/O SLURRING OF SPEECH SINCE 1 DAY

H/O TIGHTNESS OVER 4 LIMBS SINCE 1 DAY .

H/O ALTERED SENSORIUM SINCE 2 days 

Patient was taken to hospital today morning and was taken to higher center with spo2 68% at RA.

H/o palpitations, sweating  when ever he had fever history.

No h/o chest pain 

NO LOSS OF WEIGHT AND APETITE.

PAST HISTORY:

Patient is known case of COPD since 1 year 

Known case of HTN 1 year ( TELMA 10 MG )

S/P RIGHT FEMUR PFN IN 2012.

8/2/22 - hospital medications prescribed 

FAMILY HISTORY:

Not significant 

PERSONAL HISTORY: 

CHRONIC  SMOKING HISTORY SINCE 30 years young age stopped 10 years ago with 1 pack per day

Ocassional alcoholic

GENERAL EXAMINATION:

Patient is conscious, coherent, co operative 

Vitals at admission :

GCS : E1V1M1

Temperature: 98F

Pulse rate : 36 BPM

Respiratory rate: 10Cpm

BP : Not recordable

Spo2 : 68% at RA 

Cardiovascular system:

S1, S2 heard 

No murmurs 

Respiratory system:  SILENT CHEST

Per abdomen :

Soft , non tender 

Bowel sounds present 

Central nervous system : LEVEL OF CONCIOUSNESS -COMA 

SPEECH - APHASIC.

INVESTIGATIONS:

MDCT SCAN BRAIN - PLAIN

FINDINGS - OLD LACUNAR INFARCT IN LEFT THALAMUS , BILATERAL LENTIFORM NUCLEUS , RIGHT INTERNAL CAPSULE , LEFT CORONA RADIATA.

Arterial blood gas : 4/5/22 - 2:16 pm 

4/5/22 3:31 pm

4/5/22 - 6:12 pm 

4/5/22 - - 10:50 pm 

5/5/22 - 7:30 am 

5/5/22 - 11:26 am 

5/5/22 - 1:57 pm 

5/5/22 -  2:18pm

5/5/22 - 5:31 pm 

5/5/22 - 6:23 pm

5/5/22 - 10:30 pm

pH -7.224

pCO2 -64.7mm hg 

pO2 - 326mm hg 

ctHb - 13.5g/dL

sO2 -98.7%

cHCO3 - 22.1mmol/L

cNa+ - 133 mmol/L

cK+ - 3.4 mmol/L

cCa+ - 0.52 mmol/L

cCl- - 92 mmol/ L

6/5/22 - 4:31 am 

6/5/22 - 7:05 am 

6/5/22 - 11:30 am 

6/5/22 - 3:12 pm

6/5/22 - 10 :45 pm 

7/5/22 - 6:42 am

7/5/22 - 11 :56 am 

7/5/22 - 10:54 pm 

8/5/22 - 7:10 am 

8/5/22 - 1:06 pm

8/5/22 - 6:26 pm

9/5/22 - 5:54 am

9/5/22 - 11:09 am

9/5/22 - 5:36 pm

COMPLETE BLOOD PICTURE -

Haemoglobin -12.4gm/dL

Total count - 10,200cells/cumm

Neutrophils -84

lymphocytes-13

Eosinophils-01

Monocytes -02

Basophils -00

Platelet Count - 2.19 lakhs/cu.mm

9/5/22 

ESR - 20 mm/ 1st hour

PROTHROMBIN TIME - 20 SEC 

INR - 1.4

BLEEDING TIME - 2 MIN 

CLOTTING TIME - 4 MIN 30 SEC

APTT - 38 SEC

D DIMER - 12,530 ng/ml

RFT -  4/5/22  

6/5/22 rft 

7/5/22 rft5

9/5/22 RFT

 

LFT - 4/5/22

6/5/22

CHEST X RAY - 

CHEST X RAY IMMEDIATELY AFTER INTUBATION - 

7/5/22 xray 

Urine protien/creat ratio 6/5/22

Urine electrolytes 7/5/22

SERUM URIC ACID,SERUM CREATININE , BUN, BLOOD UREA - 6/5/22

TROP I - 115.6 pg/ml

ECG 

1:05 pm 

1:45 pm 

D dimer 9/5/22

Blood grouping and RH type :

A POSITIVE 

PROVISIONAL DAIGNOSIS - Respiratory acidosis secondary to(resolving) acute exacerbation of COPD with altered sensorium secondary to CO2 narcosis with past h/o HTN  ?post cpr inducedvhemopneumothorax with s/p rt sided chest drain insitu.

TREATMENT GIVEN - PATIENT HAS BEEN INTUBATED WITH MIDAZOLAM AND SCOLINE. 

CPR WAS STARTED IMMEDIATELY AT 1:10 PM AFTER INTUBATION CONSECUTIVELY WITH 4 CYCLES WITH INJ ADRENALINE 1 MG AND WAS RESUSCITATED 4TH TIME AND HE IS  CONNECTED  ON MECHANICAL VENTILATION.

TUBE THORACOSTOMY WAS DONE AT 5TH ICS IN MID AXILLARY LINE AND INTERCOSTAL DRAIN OF 24 F WAS PLACED.

1 INJ HYDROCORT 100 MG /IV/TID

2 NEB WITH DUOLIN ABD BUDECORT 2ND HOURLY

3 INJ PIPTAZ 4.5 GM IV/STAT followed by TID

4 INJ PAN 40 MG IV / OD

5 INJ OPTINEURON 1 AMP IN 100 ML NS /IV /OD

6 INJ HEPARIN 5000 IV/QID

7 BP, PR , SPO2 MONITORING

8 ET AND ORAL SUCTIONING EVERY HOURLY.

Soap notes day 1 icu bed no 3
S- no fresh complaints
O-
O/E pt on mechanical ventilator
Bp: 140/80 mm hg
Pr: 77 bpm
Rr: 20 com
Cvs :s1s1 +
Rs: BAE+
P/A: soft , nontender
Grbs: 154mg/dl
I/O = 1100/200
Ventilator settings:
ACMV-VC mode
Rr: 20/min
FIO2: 60
PEEP: 5
VT: 400
A

Respiratory acidosis secondary to(resolving) acute exacerbation of COPD with altered sensorium secondary to CO2 narcosis with past h/o HTN with past  h/o COPD with post cpr inducedvhemopneumothorax with s/p rt sided chest drain insitu
P:
Rx:
1.inj hydrocort 100 mg /iv/tid
2.neb with duolin , budecort 2nd hrly
3. Inj piptaz 4.5 mg iv/ TID .
4. Inj pan 40 mg iv/od
5. Inj optineuron 1 aml in 100 ml ns iv /od (over 30 min)
6. Bp,pr ,spo2 monitoring hrly
7. ET oral suctioning every hrly
8.inj heparin 5000iv /od