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Pre-final Case Discussion

 30/03/2022

Samhita Ghanathay
  • This is an online E log book to discuss our patient's de-identified health data shared after taking her/his 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 patient's 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 the comment box is welcome.

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 and palpitations- diagnosed to have MI and a stent was placed.
During pre-op investigations, she was also diagnosed with Diabetes, Hypertension, OSA and Asthama for which she is on regular medications. 

*2017 -
Patient complained of shortness of breath, drowsiness and pedal edema. OSAS worsened and she was advised to be on BiPAP.

*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.

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 - non-pitting type.

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




Vitals : 

30/03/2022:
*Temperature - 98 degree 
* Pulse - 90 bpm
* Respiratory rate - 18cpm
*BP - 160/90 mm of Hg
* SpO2 - 98(on ventilator) - 35 on admission.

31/03/2022:
*Temperature- 102 degree
*Pulse- 118 bpm
*Respiratory rate- 12cpm
*BP - 160/80 mm of Hg
*SpO2 - 98 (on ventilator)

GRBS - 146mg/dL

SYSTEMIC EXAMINATION: 

* CVS - S1 S2 heard.
* Respiratory System - Reduced breath sounds on right side - infrascapular area.

* Myoclonus: 

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

Metabolic and Respiratory acidosis.

ABG day 0 evening fio2 80%
pH 7.46
PCo2 32.8
PaO2 146
HCO3 23.1
SpO2 98.5

ABG day 1 morning fio2 50%
pH 7.43
PCo2 31.9
PaO2 95.3
HCO3 22.6
SpO2 96.8

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

*ECG: 



30/03/2022


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





*Ventilator settings


*Chest X-Ray :



30/03/2022



*CT - from 2017 - 




*Sleep study : for OSAS from 2017.



PROVISIONAL DIAGNOSIS:

Type 2 Respiratory failure with obstructive sleep apnea - associated with hypertension.

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 - 

Case taken with :




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