Pre-final practical

 

75 year female brought in an unconscious state-

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

Following is a brief about the case.

CHIEF COMPLAINTS: 

A 75 year old female, home-maker by occupation and a resident of Miryalguda was brought to the casualty in an unconscious state.

HISTORY OF PRESENT ILLNESS: 

*20 years ago -  she had chest pain, palpitations and was diagnosed with MI. Stent was placed. 
During pre-op investigations, she was also diagnosed with Diabetes, Hypertension and Asthma for which she is on regular medications.

*2017 -
Patient complained of shortness of breath, drowsiness and pedal edema. 
Sleep study was done and obstructive sleep apnea was diagnosed. She was advices to be on BiPAP from then 

*December, 2021
She had similar complaints of shortness of breath frequently for which she was treated at home.
Two of these episodes were serious and needed hospital admissions - patient recovered in two days.

*March, 2022. 

6:30 am
Patient developed shortness of breath 
BP measured - increased to 180/100 mm of Hg
1 dose of Labetalol injection given 
Patient stable for 3 hours and then her condition started to deteriorate 
10:30 am
Taken to hospital 
Given a second dose of Labetalol.
Referred to a hospital in Hyderabad.
11:30 am
Patient and attendent stared for Hyderabad in an ambulance 
12:30 pm 
BP raised and pulse dropped. 
Her heart stopped functioning and she fell unconscious 
She was rushed to our hospital immediately
6 rounds of CPR was done and patient was shifted to ICU after revival.
She was then given anesthesia and put on ventilator.
She had a few episodes of abnormal movements 
(A few on 29/03/2022 - day of admission and 1 on 30/03/2022)
Note : After 2017 tests, she was advised to be on regular BiPAP.
Note : After 2017 tests, she was advised to be on regular BiPAP.


PAST HISTORY :

* History of 
- Diabetes since 5 years - Metformin Tab.
- Hypertension since 5 years - Telmisartan Tab.
- Asthma since 5 years - Ipratropium bromide and Budesonide (nebulised form when needed) 

PERSONAL HISTORY:

*Diet - Vegetarian 
* Appetite - Normal 
* Bowel and Bladder - Regular
* Sleep - Adequate 
* Allergy- None
* Addition- None

FAMILY HISTORY:

There is no significant family history.

GENERAL EXAMINATION : 

The patient is unconscious.
Well built and nourished.

Pedal edema present - upto the ankle - pitting type.

No- pallor, icterus, clubbing, cyanosis, lymphoedenopathy.






Vitals : 

On 30 March 2022 : 

*Temperature - 98 degree F
* Pulse - 90 bpm
* Respiratory rate - 18cpm
*BP - 160/90 mm of Hg
* SpO2 - 98(on ventilator) - 35 on admission.

On 31 March 2022 : 

Temperature - 102F 
Pulse 118 bpm 
RR- 12 cpm 
BP - 160/80 mmHg
Spo2 - 98(on ventilator) 
GRBS - 146 mg/dl 

SYSTEMIC EXAMINATION: 

* CVS - S1 S2 heard.
* Respiratory System - normal breath sounds heard.



INVESTIGATIONS : 
29/03/2022 :

* Hemogram- 
HB 8.5
TLC 13,600
PCV 27.4
MCH 26.6
MCHC 31
PLT 2.0
P.S NORMOCYTIC, NORMOCHROMIC with neutrophilic leucocytosis
Serum iron : 45ug/dl

RBS: 211mg/dl
HbA1c : 6.8%

*Liver Function Tests- 
TB 0.57
DB 0.16
AST 148
ALT 123
ALP 180
TP 4.7
ALB 2.2

* Renal Function tests :
Blood Urea: 49mg/dl 
S. Creatinine: 1.9mg/dl
Na 142
K 4.7
Cl 98

* CUE: 
ALB ++
Sugars nil
Pus cells 4-5
Epithelial cells 1-2

*ABG : 
ABG post CPR fio2 100%
pH 6.88
PCo2 107
PaO2 77.4
HCO3 1108
SpO2 82.5

Interpretation : Metabolic and respiratory acidosis 

ABG day 0 evening fio2 80%
pH 7.46
PCo2 32.8
PaO2 146
HCO3 23.1
SpO2 96.8

ABG day 1 morning fio2 40%
pH 7.4
PCo2 31.9
PaO2 80
HCO3 21.5
SpO2 94.7

*ECG: 

Post cpr 





On 30 March 



2D echo
Concentric LVH
Sclerotic AV
EF 58%
RVSP 35 mmHg
Diastolic dysfunction +

CXR :
 
After admission 


Cavity in right middle lobe, cardiomegaly present. 

On 30 - 03-22 : 


Cardiomegaly, pleural effusion in right lobe, consolidation of right upper lobe 


CT angiogram on 2017 





*Ventilator settings

PROVISIONAL DIAGNOSIS:
Type 2 respiratory failure with obstructive sleep apnea, came with hypertension and cardiac arrest. 

TREATMENT: 

*IVF NS/RL @50ML/HR
*Inj. Pan 40 mg IV OD
*Inj. Zofer 4 mg IV SOS
*Inj. Midazolem titrate B/W 0.1 - 3 mg/Kg 
*Inj. Atracurium @ 0.8ml/hr (10mcq/hr)
*Inj. Levipil 1gm IV STAT
*Inj. Levipil 500 mg IV TID
*Inj. Clexane 60mg sc OD
*Ryle tube feeds milk+protein 100ml, water 100ml 4hourly.
*Propped up position
*Air bed with position change 2 hourly.








Reference Log - Intern 

Case taken with :


Neha T 
  


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