Kausalya Varma, MBBS 9th semester
Roll no: 59
This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
I’ve 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.
AN 75 YEAR OLD FEMALE BROUGHT TO THE HOSPITAL IN AN UNCONSCIOUS STATE
CASE:
CHIEF COMPLAINTS:
A 75 year old female who is a home-maker by occupation and a resident of Miryalguda was brought to the casualty in an unconscious state on 29/03/22
HISTORY OF PRESENT ILLNESS:
20 years ago, the patient had chest pain, palpitations and was diagnosed with occlusion Myocardial Infarction and percutaneous coronary angioplasty was done.
In 2017, patient complained sudden onset chest pain, radiating toward the neck, shortness of breath for 2-3 weeks, drowsiness for 5 days and pedal edema for 4 days. She was admitted to the hospital for further evaluation.
Sleep study was done and obstructive sleep apnea was diagnosed. She was advised to be on BiPap support since then.
She was also diagnosed with Diabetes, Hypertension and Asthma for which she is on regular medications.
2D Echo done then showed mild concentric LVH, normal LV function, Grade-III diastolic dysfunction.
After stabilization patient was shifted to stepdown ward and treated with sartans, bipap support, antacids nebulization and other supportive care.
During the hospital stay, patient was treated with diuretics, antiplatelets, statins, antibiotics, PPI, oxygen support, NIV support and other supportive care.
In 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.
In March 2022,
4:30 am (29/03/22)
Patient developed shortness of breath, relieved on nebuliser
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8 am
Patient had SOB grade 4, taken to the local hospital
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BP measured - increased to 230/110 mm of Hg
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1 dose of Labetalol injection given
BP reduced to 160/110 mmHg
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Patient stable for 3 hours and then her condition started to deteriorate
↓
10:30 am
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
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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.
Patient came to the casualty in an unresponsive state with a non recordable BP and PR, her Sp02 was 35% on 15 lit of O2. CPR was started according to the 2020 AHA guidelines. Patient was intubated with a 7.5cm ET tube and bilateral airway entry was checked. 6 cycles of CPR was done with 1mg adrenaline given after each cycle. ROSC obtained after 6 cycles of CPR.
Post CPR vitals,
BP 170/100 mmHg
PR 110 bpm
CVS- S1 S2 normal
RS- B/L AE normal, decreased air entry in left mammary area
PAST HISTORY-
Patient is a known case of obstructive sleep apnea since 2016 and on home BiPAP for the past 3 months
- Diabetes since 5 years - Metformin Tab.
- Hypertension since 5 years - Telmisartan Tab.
- Asthma since 5 years - Ipratropium bromide and Budesonide (nebulised form when needed)
No other relevant medical or surgical history
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, up to the level of the knees, pitting type.
No Pallor, icterus, clubbing, cyanosis, lymphadenopathy.
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, JVP NORMAL, Apex beat 5th IV space mid clavicular lines
Respiratory System - Normal vesicular breath sounds heard, bilateral air entry normal currently
On admission, decreased air entry right side IMA, IAA, ISA
Per Abdomen- Soft and non tender, bowel sounds heard
CNS-
-Patient has hypotonia of all four limbs
- Reflexes were elicited as shown below, on 31/03/2022
- Corneal reflex, dolls eye sign, light reflex were all absent for the patient
INVESTIGATIONS :
29/03/2022
Hemogram
RBC 3.19
HB 8.5
TLC 13,600
PCV 27.4y
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
30/03/2022
ECG
Post CPR-
2D ECHO
Concentric LVH
Sclerotic AV
EF 58%
RVSP 35 mmHg
Diastolic dysfunction +
Chest XRay
After admission
Cavity in right middle lobe, cardiomegaly present.
Cardiomegaly, pleural effusion in right lobe, consolidation of right upper lobe (2017)
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.
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