A 35 YEAR OLD MALE WITH C/O SOB

MEDICAL CASE

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

CASE DISCUSSION:

A 35 year old male came with complaints of 

• fever since 5 days
• cough since 2 days 
• breathlessness since 1 day

HOPI:

Pt was apparently assymptomatic 5 days back then developed fever which was high grade,intermittent, and associated with chills, relieved on taking medication not associated with vomitings, burning micturition, loose stools.2 days later patient complained of cough  with bloody expectoration and shortness of breath (grade II),aggrevated on lying down and relieved in sitting position.For which he was admitted to a private hospital 1 day back and as the symptoms aggravated he was shifted to our hospital. Presently patient complaints of SOB (grade IV) and cough.

PAST HISTORY: Not a k/c/o DM,htn,tb,asthma,epilepsy 

PERSONAL HISTORY:

He is married 

Daily wage labourer by occupation (not going to work since 1 month)

Consumes mixed diet 

Appetite reduced

Bowel n bladder regular 

Sleep adequate 

Addictions: 

Consumes Alcohol since 15 years, stopped 5 years back on his own will and then started 2 months back, consumes 2 bottles/day (country liquor)

Last consumed 6 days back 1 quater

Consumes khaini (chewable tobacco) since 15 years everyday 2 packs

Last consumed 3 days back 1 packetShe is Married

FAMILY HISTORY:

No similar complaints in family 

CLINICAL IMAGES:

GENERAL EXAMINATION:

Pt is conscious, coherent and cooperative 

Moderately built and nourished.

On admission:

BP:140/80mmhg

PR:66bpm

RR:46cpm

SPO2: 67% on RA

GRBS: 94mg/dl

SYSTEMIC EXAMINATION:

CVS: S1,S2, +

RS: B/L diffuse crepts, air entry decreased in right lower lobe 

P/A:Soft, Non tender

CNS: NAD

PROVISIONAL DIAGNOSIS: 

COMMUNITY ACQUIRED PNEUMONIA WITH PULMONARY OEDEMA ?ARDS.

INVESTIGATIONS:

Day 1: ABG at 6:30pm

Day 1: ABG at 11:00pm

Day 2: ABG  at 6:00am

Day 2

S: Pt on O2 of 10ltrs and intermittent CPAP

Complaints of BACK PAIN 

Fever spikes present

O:

VITALS: 

BP: 130/80mmhg 

PR: 79bpm 

RR: 22cpm 

Temp: 98.6f 

GRBS: 125mg/dl at 6:00am   

SpO2: 68%

SYSTEMIC EXAMINATION: 

CVS: s1,s2 no added sounds 

P/A: not tender,Soft 

RS: BAE+ B/L DIFFUSE CREPTS

CNS: NAD

A: COMMUNITY ACQUIRED PNEUMONIA WITH PULMONARY OEDEMA 

P: 

INJ.Zofer

Inj.Pan

Inj.Lasix

Inj.Neomol  1g/iv sos if temp >101f

Tab.Dolo 650mg RT/TID

nebulisation

Budecort 12 th hrly

Duolin 8 th hrly

 

Day 3

S: SOB decreased 

Fever spikes present

O:

Pt on O2 of 16 ltrs and intermittent CPAP

VITALS: 

BP: 140/70mmhg 

PR: 98bpm 

RR: 18cpm 

Temp: 100.7f    

SpO2: 77% on 16ltrs of O2

On CPAP - PC mode with NIV - Spo2 90% on FiO2 50

SYSTEMIC EXAMINATION: 

CVS: s1,s2 no added sounds 

P/A: not tender,Soft 

RS: BAE+ B/L DIFFUSE CREPTS

CNS: NAD

A: COMMUNITY ACQUIRED PNEUMONIA WITH PULMONARY OEDEMA 

P: 

INJ.Zofer 4mg po/bd

Inj.Pan 40mg po/od

Inj.Piptaz 4.5gm iv/tid

Inj.Neomol  1g/iv sos if temp >101f

Tab.Dolo 650mg RT/TID

nebulisation

Budecort 12 th hrly

Duolin 8 th hrly

2D echo review: https://youtu.be/sNhmD0wDU1w

Day 4

S: pt was intubated yesterday afternoon due to hypoxia

Fever spikes present

O:

Pt on ACMV/VC MODE 

RRtotal:16

RR:16

FiO2:100

Peep:8

Vt:450

VITALS: 

BP: 140/70mmhg 

PR: 98bpm 

RR: 18cpm 

Temp: 100.7f    

SpO2: 77% on 16ltrs of O2

On CPAP - PC mode with NIV - Spo2 90% on FiO2 50

SYSTEMIC EXAMINATION: 

CVS: s1,s2 no added sounds 

P/A: not tender,Soft 

RS: BAE+ B/L DIFFUSE CREPTS

CNS: NAD

A: COMMUNITY ACQUIRED PNEUMONIA WITH PULMONARY OEDEMA 

P: 

INJ.Zofer 4mg po/bd

Inj.Pan 40mg po/od

Inj.Piptaz 4.5gm iv/tid

Inj.Neomol  1g/iv sos if temp >101f

Tab.Dolo 650mg RT/TID

nebulisation

Budecort 12 th hrly

Duolin 8 th hrly

ABG:

DEATH SUMMARY:

A 35 YEAR OLD MALE PATIENT CAME TO CASUALITY ON 16/09/2022 WITH CHIEF COMPLAINTS OF FEVER SINCE 5 DAYS, SOB SINCE 3 DAYS, BLOOD STAINED SPUTUM SINCE 2 DAYS,HIGH GRADE FEVER ASSOCIATED WITH CHILLS AND RIGOR.SOB WHICH IS GRADUALLY PROGRESS TO GRADE II. VITALS

ON PRESENTATION PT WAS CONSCIOUS,COHERENT AND TACHYPNEAC AND ABG AT THE TIME OF ADMISSION WAS SHOWING TYPE 1 RESPIRATORY FAILURE.

ON EXAMINATION:

PT WAS CONSCIOUS,COHERENT BP:140/80MMOFHG

PR:87BPM

TEMP:99.9F

RR:48CPM SPO2:87%

WITH CLINICAL DIAGNOSIS AND INVESTIGATIONS OUR PROVISIONAL DIAGNOSIS IS COMMUNITY ACQUIRED PNEUMONIA WITH MODERATE ARDS WITH ALCOHOL DEPENDENCE SYNDROME WITH ALCOHOLIC HEPATITIS.

PATIENT WAS STARTED ON ANTIBIOTICS AND OTHER SUPPORTIVE CARE.VITALS ARE MONITERED EVERY 4TH HOURLY.

PATIENT ATTENDERS ARE COUNSELLED ABOUT THE INDICATION OF INTUBATION IN VIEW OF FALLING SATURATIONS BUT THEY DENIED.

ON DAY 4 IN VIEW OF HYPOXIA PATIENT WAS INTUBATED AND CONNECTED TO MECHANICAL VENTILATOR SEVERAL ABG'S WERE DONE AND VENTILATOR SETTINGS ARE CHANGED ACCORDINGLY. ET CULTURE ARE SENT AND REPORT AWAITED. POST INTUBATION PATIENT HAD CONTINOUS FEVER SPIKES.

ON DAY 5 AT AROUND 1:50 AM ON 21/09/2022 PATIENT CENTRAL AND PERIPHERAL PULSES WERE NOT PALPABLE CPR WAS INITIATED ACCORDING AHA 2020 GUIDLINES AND CONTINUED FOR 30 MINS DESPITE OF RESUSCITATIONS EFFORT PATIENT COULD NOT BE REVIVED AND DECLARED DEAD BY STRAIGHT LINE ECG AT 2:25 AM.

IMMEDIATE CAUSE OF DEATH: SEVERE ARDS

ANTECEDENT CAUSE OF DEATH:COMMUNITY ACQUIRED PNEUMONIA WITH BOTH LUNGS CONSOLIDATION WITH ALCOHOL DEPENDENCE SYNDROME WITH ALCOHOLIC HEPATITIS.