ALTERED SENSORIUM SECONDARY TO ? CO2 NARCOSIS MIXED (RESPIRATORY AND METABOLIC) ACIDOSIS COMMUNITY ACQUIRED PNEUMONIA (LEFT LOWER LOBE CONSOLIDATION) B/L PLEURAL EFFUSION (LEFT >RIGHT) HYPERKALEMIA (RESOLVED) TYPE 2 RESPIRATORY FAILURE MODERATE TO SEVERE PAH TYPE 1 RIGHT TROCHANTERIC FRACTURE GRADE 2 AND GRADE 4 BEDSORE OVER RIGHT GLUTEAL REGION.

Case History and Clinical Findings 
C/O SHORTNESS OF BREATH SINCE 3 DAYS HOPI:
 PATIENT WAS APPARENTLY ALRIGHT 20 DAYS BACK, AND HAD H/O GIDDINESS AND H/O FALL AND SUSTAINED INJURY TO RIGHT HIP AND WAS DIAGNOSED WITH RIGHT INTERTROCHANTERIC FRACTURE. PATIENT WAS ADMITTED AND SYMPTOMATIC TREATMENT WAS GIVEN. PATIENT WAS BEDRIDDEN AFTER THE FRACTURE AND DEVELOPED GRADE 2-3 BEDSORES OVER RT GLUTEAL REGION WHICH HAS BEEN NOTICED YESTERDAY. PATIENT DEVELOPED GENERALISED WEAKNESS AND HAD NO FOOD INTAKE SINCE YESTERDAY. SHE DEVELOPED SOB EVEN ON REST, ORTHOPNEA +, PND+. NO RELIEVING FACTORS NOTED , AGGRAVATED ON TALKING. H/O COUGH WITH MUCOID EXPECTORATION YESTERDAY.NO C/O FEVER, COLD, BURNING MICTURITION, CHEST PAIN, PALPITATIONS, DECREASED URINE OUTPUT, PEDAL EDEMA. 
PAST HISTORY : 
NOT A K/C/O HTN, DM, CVA, CAD, TB, EPLIEPSY, ASTHMA. 
GENERAL EXAMINATION: 
PATIENT IS C/C/C BP= 140/80 MMHG PR = 118 BPM RR = 20 CPM SPO2 = 80 % TEMP = 99.2 F GRBS = 114 MG/DL 
SYSTEMIC EXAMINATION: 
RS = BAE+, NVBS +, B/L CREPTS +, MA, IAA CVS = S1 S2 +, NO MURMURS
 P/A = SOFT, NONTENDER
COMPLETE BLOOD PICTURE (CBP)
 16-08-2023 
HAEMOGLOBIN8.8 gm/dl
TOTAL COUNT-:15700
NEUTROPHILS83 %
LYMPHOCYTES07 %
EOSINOPHILS01 %
MONOCYTES09 %
BASOPHILS00 %
PLATELET COUNT6.0
SMEAR-:
Normocytic normochromic Anemia with neutrophilic leucocytosis
RFT 16-08-2023 
UREA52 mg/dl
CREATININE1.0 mg/dl
URIC ACID4.3 mg/dl
CALCIUM9.2 mg/dl
PHOSPHOROUS3.3 
 SODIUM139  
POTASSIUM6.0 
CHLORIDE102 mEq/
ABG 16-08-2023  
PH7.233
PCO252.8
PO278.6
HCO321.5
St.HCO319.6
BEB-5.8
BEecf-4.9
TCO245.6
O2 Sat94.2
O2 Count15.1
RFT 16-08-2023 
UREA50 mg/dl
CREATININE1.0 mg/dl
URIC ACID4.2 mg/dlCALCIUM10.2 mg/dl
PHOSPHOROUS3.5 mg/dl
SODIUM138 mEq/L
POTASSIUM5.6
CHLORIDE105
LIVER FUNCTION TEST
Total Bilurubin0.69 
Direct Bilurubin0.20 mg/dl
SGOT(AST)12 IU/L
SGPT(ALT)11 IU/L
ALKALINE PHOSPHATE521 IU/L
TOTAL PROTEINS5.8 gm/dl
ALBUMIN2.61 gm/dl
A/G RATIO0.82
HBsAg-RAPIDNegative 
Anti HCV Antibodies - RAPIDNon Reactive RFT 17-08-2023 
UREA48 mg/dl50-17 mg/dl
CREATININE0.8 mg/dl
URIC ACID3.1 mg/dl
CALCIUM9.6 mg/dl
PHOSPHOROUS3.4 mg/dl
SODIUM136 mEq/L
POTASSIUM5.9 mEq/L
CHLORIDE104 mEq/L
RFT 18-08-2023 
UREA50 mg/dL
CREATININE1.0 mg/dl
URIC ACID4.5 mg/dl
CALCIUM10.0 mg/dl
PHOSPHOROUS2.5 mg/dl
SODIUM142 mEq/L
POTASSIUM6.0 mEq/L
CHLORIDE102 mEq/L
COMPLETE URINE EXAMINATION (CUE) 18-08-2023 
 COLOURPaleyellow
APPEARANCEClear
REACTIONAcidic
SP.GRAVITY1.010
ALBUMIN+SUGARNil
BILE SALTSNil
BILE PIGMENTSNil
PUS CELLS3-6
EPITHELIAL CELLS2-2
RED BLOOD CELLSNil
CRYSTALSNil
CASTSNil
AMORPHOUS DEPOSITSAbsent
OTHERSNil
ABG 18-08-2023  
PH7.24
PCO251.8
PO257.1
HCO321.6
St.HCO319.8
BEB-5.5
BEecf-4.6
TCO245.8
O2 Sat88.0
O2 Count14.1
SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 1808-2023 SODIUM137  mEq/L
POTASSIUM4.3  mEq/L
CHLORIDE102 mEq/L
CALCIUM IONIZED1.49 mmol/Lmmol/L
RFT 19-08-2023 
UREA37 mg/dl
CREATININE0.9 mg/dl
URIC ACID4.1 mg/DL
CALCIUM10.2 mg/dl
PHOSPHOROUS3.1 mg/dl
SODIUM136 mEq/L
POTASSIUM5.0 mEq/L
CHLORIDE102 mEq/L
ABG 19-08-2023 
 PH7.23
PCO249.1
PO266.0
HCO320.1
St.HCO318.7
BEB-7.0
BEecf6.1
TCO242.2
O2 Sat91.6
O2 Count16.3
ABG 19-08-2023 
 PH7.24
PCO246.0
PO244.6
HCO319.2
St.HCO318.0
BEB-7.6
BEecf-6.9
TCO240.5
O2 Sat79.7
O2 Count13.3
RFT 20-08-2023 
UREA45 mg/dl
CREATININE1.1 mg/dl
URIC ACID4.7 mg/dl
CALCIUM9.4 mg/dl
PHOSPHOROUS3.2 mg/dl
SODIUM136 mEq/L
POTASSIUM5.2 mEq/L
CHLORIDE99 mEq/L
ABG 20-08-2023
  PH7.13
PCO248.8
PO283.7
HCO315.8
St.HCO314.7
BEB-12.1
BEecf-11.6
TCO235.8
O2 Sat93.1O2 Count10.3RFT 21-08-2023 04:39:AM UREA59 mg/dl50-17 mg/dlCREATININE1.0 mg/dl1.2-0.6 mg/dlURIC ACID5.0 mg/dl6-2.6 mg/dlCALCIUM10.0 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.8 mg/dl4.5-2.5 mg/dlSODIUM139 mEq/L145-136 mEq/LPOTASSIUM5.0 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/LABG 21-08-2023 04:39:AM PH6.94PCO255.7PO2151HCO311.5St.HCO39.9BEB-19.2BEecf-18.4TCO227.9O2 Sat93.6O2 Count9.6BLOOD UREA22-08-2023 03:48:AM59 mg/dl50-17 mg/dlSERUM CREATININE22-08-2023 03:48:AM1.0 mg/dl1.2-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 22-08-2023 03:48:AM SODIUM138 mEq/L145-136 mEq/LPOTASSIUM4.7 mEq/L5.1-3.5 mEq/LCHLORIDE101 mEq/L98-107 mEq/LCALCIUM IONIZED1.20 mmol/Lmmol/LSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 22-08-2023 10:50:AM SODIUM134 mEq/L145-136 mEq/LPOTASSIUM4.9 mEq/L5.1-3.5 mEq/LCHLORIDE98 mEq/L98-107 mEq/LCALCIUM IONIZED1.21 mmol/Lmmol/LABG 23-08-2023 12:48:AM PH7.23PCO245.7PO232.9HCO318.9St.HCO317.7BEB-7.8BEecf-7.3TCO240.9O2 Sat64.7O2 Count9.1ABG 23-08-2023 02:30:AM PH7.14PCO262.9PO244.4HCO320.9St.HCO317.5BEB8.1BEecf-6.7TCO246.0O2 Sat75.1O2 Count11.6ABG 23-08-2023 02:48:AM PH7.21PCO256.2PO222.5HCO321.9St.HCO318.7BEB-5.8BEecf-4.8TCO247.5O2 Sat39.6O2 Count6.2BLOOD UREA23-08-2023 05:03:AM61 mg/dl50-17 mg/dlSERUM CREATININE23-08-2023 05:03:AM1.1 mg/dl1.2-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 23-08-2023 05:03:AM SODIUM137 mEq/L145-136 mEq/LPOTASSIUM4.8 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/LCALCIUM IONIZED1.20 mmol/Lmmol/LABG 23-08-2023 06:47:AM PH7.13PCO268.1PO275.9HCO321.8St.HCO318.3BEB-7.4BEecf-6.1TCO248.7O2 Sat92.9O2 Count12.5ABG 24-08-2023 12:24:AM PH7.07PCO277.0PO240.9HCO321.6St.HCO316.6BEB-9.3BEecf-7.2TCO248.6O2 Sat72.5O2 Count11.0ABG 24-08-2023 07:28:AM PH7.07PCO274.7PO236.2HCO321.0St.HCO316.0BEB10.1BEecf-7.7TCO246.8O2 Sat68.8O2 Count11.6 2D ECHO REPORT:-TACHYCARDIA-NO RWMA-MODERATE TO SEVERE TR WITH PAH( 52 + 20 = 72 MMHG)-MILD TO MODERATE AR +, MILD TO MODERATE MR +-SCLEROTIC AV-NO AS/MS-EF = 58-GOOD LV SYSTOLIC FUNCTION-DIASTOLIC DYSFUNCTION +, NO PE-IVC SIZE (1.62 CM), MILD DILATED COLLAPSING-MILD DIFFUSED R.V. (4.02 CM)-DILATED RA / LA-IAS --- ANEURYSM
Diagnosis
 ALTERED SENSORIUM SECONDARY TO ? CO2 NARCOSIS MIXED (RESPIRATORY AND METABOLIC) ACIDOSIS COMMUNITY ACQUIRED PNEUMONIA (LEFT LOWER LOBE CONSOLIDATION) B/L PLEURAL EFFUSION (LEFT >RIGHT) HYPERKALEMIA (RESOLVED) TYPE 2 RESPIRATORY FAILURE MODERATE TO SEVERE PAH TYPE 1 RIGHT TROCHANTERIC FRACTURE GRADE 2 AND GRADE 4 BEDSORE OVER RIGHT GLUTEAL REGION.
 Treatment Given
 1. OXYGEN SUPPLEMENTATION @ 2 L /HR 2. INTERMITTENT NIV SUPPORT 
3. RT FEEDS --- WATER (100 ML) 2ND HOURLY, MILK (200ML) 4TH
4. IV FLUIDS NS @ 50ML/HR 
5. INJ. PIPTAZ 2.23 GM/IV/BD 8AM AND 8PM 
6. INJ. CLINDAMYCIN 600MG/ IV/BD 8AM AND 8 PM 
7. INJ. HAI IOU IN 25D IV /SOS (IF POTASSIUM >5.2) 
8. INJ. CLEXANE 49 MG S/C OD 
9.TAB. AZITHROMYCIN 500 MG RT/ OD 
10. NEB IPRAVENT + BUDECORT 6TH HOURLY 
11. INJ. MAGNEX FORTE 1.5 GM 
12. REGULAR DRESSING FOR BEDSORE. 
13. PASSIVE PHYSIOTHERAPY
 14. POSITION CHANGE 2 ND HOURLY 
15. MONITAL VITALS STRICTLY 
Advice at Discharge
 DEATH SUMMARY
 A 85 YEAR OLD FEMALE, K/CO RIGHT INTERTROCHANTERIC FRACTURE, SINCE 20 DAYS ON CONSERVATIVE MANAGEMENT WITH GRADE 2 AND GRADE 4 BEDSORE ON THE RIGHT GLUTEAL REGION SINCE 10 DAYS, PRESENTED TO THE HOSPITAL WITH C/O SHORTNESS OF BREATHSINCE 2-3 DAYS WHICH WAS PRESENT EVEN ON REST (GRADE 4 MMRC). ABG SHOWED MIXED ACIDOTIC PATTERN. SPO2 WAS 98% ON 4 L O2. CTPA IN V/O PULMONARY EDEMA WAS DONE WHICH SHOWED CONSOLIDATION IN LATERAL ASPECT OF LEFT LOWER LUNG LOBE. SEGMENTAL ATELECTASIS IN APICO - POSTERIOR SEGMENT FO LEFT LOWER LOBE WITH B/L PLEURAL EFFUSION ( MILD ON RIGHT, MODERATE ON LEFT SIDE). IV ANTIBIOTICS WERE STARTED ACCORDINGLY. PATIENT WAS IN TYPE 2 RESPIRATORY FAILURE WITH MODERATE TO SEVERE PAH TYPE 1. INITIALLY SPO2 WAS 98% ON 4 L OXYGEN, GRADUALLY THE OXYGEN REQUIREMENT INCREASED TO 8-9 L OXYGEN. INTERMITTENT BIPAP SUPPORT WAS GIVEN, EVENTUALLY PATIENT WAS ON NON INVASIVE VENTILLATION WITH PRESSURE SUPPORT I/V/O LOW GCS AND LOW SATURATION, TYPE 1 RESPIRATORY FAILURE. PATIENT WAS INTUBATED ON 24/8/23 AND 7MM TUBE WAS PLACED AND CONFIRMED WITH 5 POINT AUSCULTATION. IMMEDIATELY AFTER INTUBATION, PATIENT HAD SUDDEN FALL IN SATURATION AND PULSE AND PATIENT WENT INTO CARDIAC ARREST AROUND 11.45 AM ON 24/08/23. CPR WAS INITIATED ACCPRDING TO ACLS GUIDELINES AND CONTINUED FOR AROUND 30 MINS. INSPITE OF ABOVE EFFORTS, PATIENT COULD NOT BE REVIVED. PATIENT WAS DECLARED DEAD AT 12.19 PM.IMMEDIATED CAUSE OF DEATH : TYPE 1 RESPIRATORY FAILURE ANTECEDANT CAUSE OF DEATH : SYNPNEUMONIC EFFUSION CHRONIC TYPE 2 RESPIRATORY FAILURE, MODERATE TO SEVERE PAH TYPE 1 RIGHT INTERTROCHANTERIC FRACTURE GRADE 2 AND GRADE 4 BEDSORE OVER RIGHT GLUTEAL REGION. When to Obtain Urgent Care IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Comments

Post a Comment

Popular posts from this blog

CKD CASE

CKD CASE 20,06,2022 CASE SCENARIO  Pt aged 70 years came to opd with chief complaints of flank pain and decreased urine output  HISTORY OF PRESENT ILLNESS  Since a week pt has flank pain and decreased urine output   HISTORY OF PAST ILLNESS Pt was asymptomatic 4years back than he met with an accident for which he has been taking medication for pain as post operative medication for pain as a result of chronic use of pain medication pt's kidneys got gradually damaged which resulted in kidney failure  TREATMENT HISTORY  patient is on hypertensive therapy since 3 years and pain killers  PERSONAL HISTORY  Regular bowel habbit  Mixed diet  Decreased urine out put  PHYSICAL EXAMINATION  .patient is conscious,coherent ,and cooperative  .moderately built and moderately nourished  .No signs of --pallor                           .icterus                           .clubbing                           .cynosis     .no edema present    .  VITALS   .Temperature-:98.4F   .pulse rate     -:86   .Rp 
Read more

DIABETIC KETOACIDOSIS

Image
A50 yr old female came to GM OPD with chief complaints of fever, vomiting, difficulty in breathing. HISTORY OF PRESENTING ILLNESS:- patient was apparently asymptomatic 2 weeks back then she developed fever of low grade with vomiting 4 episodes per day which is non-bilious, non-projectile. HISTORY OF PAST ILLNESS:- K/C/O- DM since 20yrs K/C/O- HTN since 20yrs. Not a K/C/O of TB, ASTHMA, EPILEPSY TREATMENT HISTORY:- METFORMIN since 20yrs TELMISARTAN since 20yrs PERSONAL HISTORY:- Diet- mixed Appetite- normal Bowel and bladder habits- regular Burning micturition No addiction FAMILY HISTORY:- Not significant PHYSICAL EXAMINATION:- #GENERAL:- No pallor No icterus No cyanosis No clubbing No lymphadenopathy Vitals:- B.p- 140/90mmHg Pulse-  Temp- Afebrile Respiratory rate- 18/min #Systemic examination:- CVS- S1,S2 heard           No cardiac murmurs           No thrills Respiratory system- dyspnoea present                                       No wheeze                                       Pos
Read more

HEART FAILURE WITH MID RANGE EJECTION FRACTION( EF 44%) WITH RIGHT LOWER LOBE COLLAPSE WITH BRONCHIECTASIS WITH RIGHT MIDDLE LOBE PLEURAL EFUSION WITH CHRONIC PANCREATITIS WITH SEPSIS WITH GRADE 2 BED SORE WITH K/C/O DM II SINCE 20 YEARS WITH K/C/O CAD-S/P: PTCA DONE 2 YEARS AGO D9-S/P: TRACHEOSTOMY

Case History and Clinical Findings  PATIENT CAME WITH C/O LOWER BACK ACHE SINCE 3 WEEKS RADIATING TO LEFT LOWER LIMB  HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIOC 3 WEEKS BACK SINCE THEN, PATIENT COMPLAINTS OF LOWER BACK ACHE WHICH IS SUDDEN ONSET,NON PROGRESSIVE,AGRAVATES ON MOVEMENT RELEIVES ON REST H/O TRAUMA(SLIP AND FALL FROM STEPS) 3 WEEKS BACK ,WAS TAKEN TO OUTSIDE HOSPITAL FOUND TO HAVE L5 BURST FRACTURE ON CT PELVIS AND CAME HERE FOR FURTHER MANAGEMENT NO H/O LIFTING OF HEAVY WEIGHTS,FEVER BURNING MICTURITION BOWEL AND BLADDER INCONTINENCE PAST HISTORY OF RIGHT PROXIMAL FEMUR FRACTURE AND DONE IMILN 10 YEARS BACK. H/O PTCA DONE ONE AND HALF YEAR BACK AND IS ON REGULAR MEDICATION  K/C/O DM II SINCE 20 YEARS AND IS ON T. METFORMIN 500 MG + T. VOGLIBOSE 0.2 MG + T. GLIMIPERIDE 2 MG GENERALEXAMINATION:  PATIENT IS CONSCIOUS,COHERENT AND CO OPERATIVE NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,EDEMA AND LYMPHADENOPATHY  VITALS: TEMP:AFEBRILE BP: 110/80MMHG PR:80BPM RR:18CPM  SYSTEMIC
Read more