This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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 comments in comment box are most welcomed
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 76years old female housewife by occupation brought with complaints of
- chest pain since yesterday
- SOB since morning
HOPI:
Patient was apparently asymptomatic 2yrs and was diagnosed with hypertension (is on medication not known). 2yrs back was admitted at a private hospital for liver problem- cholelithiasis -done cholecystectomy.
Presently- complained of chest pain since yesterday associated with 2 episodes of Vomiting,Sweating and 2 episodes of loose motions.
Was taken to RMP and was given 1 injection and tablet and brought back to home.
Since today morning she complained of discomfort and was brought to casualty .
PAST HISTORY:
Not a k/c/o - DM,TB,ASTHMA,EPILEPSY
PERSONAL HISTORY:
She is Married
She consumes
- Mixed diet
- sleep is adequate
- Appetite normal
- bowel and bladder movements are regular
MENSTRUAL HISTORY: attained menopause 15 years back
FAMILY HISTORY:
No similar complaints in family
GENERAL EXAMINATION:
At time of admission
Pt is drowsy,extremities were cool and clamy
PR-75bpm
Bp-60/40mmhg
Spo2-57% ON RA
CVS-S1,S2 +, no added sounds
RS- b/l diffuse crepts on inspiration
P/A-Soft,NT Scar present at the right hypochondriac region (kochers incision for cholecystectomy)
CLINICAL IMAGES:
INVESTIGATIONS:
2D ECHO: https://youtu.be/D3m0t9MIGxU
ABG:Day1 at 4:40pm
Serum lactate: 31
DIAGNOSES: CARDIOGENIC SHOCK SECONDARY TO NSTEMI WITH CARDIOGENIC PULMONARY EDEMA.
TREATMENT:
PT WAS INTUBATED IN VIEW OF HYPOXIA AND CONNECTED TO MECHANICAL VENTILATOR
In view of cardiogenic shock pt was started on inotropic support
Post intubation vitals:
Bp:90/60MMHG
Pr:140BPM
Spo2:95%
Rr:crepts decreased
Post intubation investigations:
MEDICATION:
RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hrly
Inj.PAN 40mg/IV/OD
Inj.Zofer 4mg/IV/SOS
Inj.NA 2 AMP IN 40ml NS @ 14ml/hr
Inj.doubutamine 1 amp in 45ml NS @ 15ml/he
Inj.Atracurium
Inj.Lasix 40mg iv/b
Tab Ecosprin AV 75/10 OD
Inj.Clexane 60 mg sc bd
inj.KCL 1amp in 200ml NS over 4 hrs
Vitals are monitored
Day 2
S: Pt is on mechanical ventilation and sedation
O:
Pt ACMV VC MODE
GCS: E1VTM1
RR TOTAL:23
RR:14
Fio2:100
TV:400
PEEP:5
VITALS:
BP: 110/60mmhg
PR: 138bpm
RR: 21cpm
Temp: 100.4f
GRBS: 193mg/dl at 7:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS:BAE+
K/c/o - HTN since 2 yrs
A: CARDIOGENIC SHOCK SECONDARY TO NSTEMI WITH CARDIOGENIC PULMONARY EDEMA.
P:
RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hrly
Inj.PAN 40mg/IV/OD
Inj.Zofer 4mg/IV/SOS
Inj.NA 2 AMP IN 40ml NS @ 14ml/hr
Inj.doubutamine 1 amp in 45ml NS @ 15ml/he
Inj.Atracurium
Inj.Lasix 40mg iv/b
Tab Ecosprin AV 75/10 OD
Inj.Clexane 60 mg sc bd
inj.KCL 1amp in 200ml NS over 4 hrs
Vitals are monitored
ABG:Day 2 at 1:30am
ABG:Day 2 at 1:20am
ABG:Day 2at 10:50pm
Day 3
S: Pt is on mechanical ventilation and sedation
O:
Pt ACMV VC MODE
GCS: E1VTM1
RR TOTAL:18
RR:18
Fio2:100
TV:420
PEEP:5
VITALS:
BP: 100/60mmhg
PR: 149bpm
RR: 17cpm
Temp: 98.4f
GRBS: 197mg/dl at 7:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS:BAE+
K/c/o - HTN since 2 yrs
A: CARDIOGENIC SHOCK SECONDARY TO NSTEMI WITH CARDIOGENIC PULMONARY EDEMA.
P:
RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hrly
Inj.PAN 40mg/IV/OD
Inj.Zofer 4mg/IV/SOS
Inj.NA 2 AMP IN 40ml NS @ 14ml/hr
Inj.doubutamine 1 amp in 45ml NS @ 15ml/he
Inj.Atracurium
Inj.Lasix 40mg iv/b
Tab Ecosprin AV 75/10 OD
Inj.Clexane 60 mg sc bd
inj.KCL 1amp in 200ml NS over 4 hrs
Neb:budecort and mucomist
Vitals are monitored
Day 4
S: Pt is on mechanical ventilation and sedation
O:
Pt SIMV VC MODE
GCS: E1VTM4
RR TOTAL:18
RR:18
Fio2:100
SPO2 - 94
TV:420
PEEP:6
VITALS:
BP: 80/60mmhg
PR: 116bpm
RR: 22cpm
Temp: 98.4f
GRBS: 187mg/dl at 7:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS: diffuse crepts + in all areas
K/c/o - HTN since 2 yrs
A: CARDIOGENIC SHOCK SECONDARY TO NSTEMI WITH CARDIOGENIC PULMONARY EDEMA.
P:
Starting NORAD
Monitoring vitals and GCS
ABG:Day4 at 6:20am
ABG:Day 4 at 1:20pm
2D ECHO REVIEW:
Day 5
S: Pt is on mechanical ventilation and sedation FEVER SPIKES SINCE YESTERDAY AFTERNOON
O: Pt SIMV VC MODE
GCS: E1VTM4
RR TOTAL:20
RR:20
Fio2:70
SPO2 - 100
TV:440
PEEP:6
VITALS:
BP: 100/60mmhg
PR: 110bpm
RR: 22cpm
Temp: 102.6f
GRBS: 161mg/dl at 7:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS: diffuse crepts + in all areas K/c/o - HTN since 2 yrs
A: CARDIOGENIC SHOCK SECONDARY TO NSTEMI WITH CARDIOGENIC PULMONARY EDEMA.
P:
Monitoring vitals and GCS
titrating sedation and monitoring the response
Day 6:
Day 7:
Day 8
S: Pt is on day 8 of mechanical ventilation
FEVER SPIKES Present
Icterus +
O: Pt CPAP VC MODE
GCS: E1VTM4
RR TOTAL:30
RR:14
Fio2:30
SPO2 - 91
PEEP:6
VITALS:
BP: 110/90mmhg
PR: 132bpm
RR: 34cpm
Temp: 103.3f
GRBS: 225mg/dl at 6:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS: diffuse crepts + in all areas K/c/o - HTN since 2 yrs
A: CARDIOGENIC SHOCK SECONDARY TO NSTEMI WITH CARDIOGENIC PULMONARY EDEMA.
P:
Plan for CECT in view of R hemiparesis
Plan for tracheostomy in view of prolonged ventilation
Day 9
Day 10
Day 11
S: Pt is on day 11 of mechanical ventilation
FEVER SPIKES Present
Icterus +
O: Pt on T-piece CPAP VC MODE
GCS: E1VTM4
Fio2:41
SPO2 - 100
PEEP:8
VITALS:
BP: 90/60mmhg
PR: 110bpm
RR: 34cpm
Temp: 102.3f
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS: diffuse crepts + in all areas K/c/o - HTN since 2 yrs
A: CARDIOGENIC SHOCK SECONDARY TO NSTEMI WITH CARDIOGENIC PULMONARY EDEMA.
P:
Plan to extubate
Day 12
S: Pt on T-piece on 10ltrs of O2
spo2:91
FEVER SPIKES Present
O:
GCS: E1VTM4
Spontaneous eye opening and eyes deviated to the side of lesion
B/L pupils reacting to light
VITALS:
BP: 90/60mmhg
PR: 106bpm
RR: 31cpm
Temp: 99.9f
GRBS: 148mg/dl at 7:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS: diffuse crepts + in all areas K/c/o - HTN since 2 yrs
A: CARDIOGENIC SHOCK SECONDARY TO NSTEMI WITH CARDIOGENIC PULMONARY EDEMA.
P:
Plan to extubate
Day 13
S: Pt extubated yesterday afternoon
FEVER SPIKES Present
O: Pt On O2 of 16ltrs
SPO2 - 92%
Spontaneous eye opening+ and deviated to the side of lesion
GCS:E4V1M5
VITALS:
BP: 100/60mmhg
PR: 105bpm
RR: 35cpm
Temp: 100f
GRBS: 151mg/dl at 7:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS: diffuse crepts + in all areas
CNS: B/L pupils NSRL
R. L
TONE: Hypo. N
POWER: 0/5. 4/5
Reflexes:
B. T. S. K. A. P
R - - - - - m
L + + + + + E
K/c/o - HTN since 2 yrs
A: CARDIOGENIC SHOCK (RESOLVED)NSTEMI WITH CARDIOGENIC PULMONARY EDEMA (RESOLVED),AKI,ALI SECONDARY TO HYPO PERFUSION WITH RIGHT HEMIPARESIS SECONDARY TO (CARDIO EMBOLIC) ACUTE INFARCT IN PARITO TEMPORAL REGION.
P:
Physiotherapy of right upper limb and lower limb
Chest physiotherapy
Inj.Levipil 500mg IV BD
Inj.Neomol 1gm iv if temp > 102f
Rt feeds 4th hrly milk 2nd hrly water
Inj.zofer 4mg iv tid
Inj.pan 40mg iv
Inj.mannitol 20% in 100ml iv
Tab.met xl 12.5 mg/po/bd
Day 17
S:
FEVER SPIKES Present
O: Pt On O2 of 6 ltrs
SPO2 - 96%
Spontaneous eye opening+ and deviated to the side of lesion
GCS:E4V1M5
VITALS:
BP: 110/70mmhg
PR: 127bpm
RR: 35cpm
Temp: 101f
GRBS: 153mg/dl at 7:00am
I/O: 2200/500ml
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS: diffuse crepts + in all areas
CNS: B/L pupils NSRL
R. L
TONE: Hypo. N
POWER: 0/5. 4/5
Reflexes:
B. T. S. K. A. P
R - - - - - m
L + + + + + E
K/c/o - HTN since 2 yrs
A: CARDIOGENIC SHOCK (RESOLVED)NSTEMI WITH CARDIOGENIC PULMONARY EDEMA (RESOLVED),PAROXYSMAL AF, AKI,ALI SECONDARY TO HYPO PERFUSION WITH RIGHT HEMIPARESIS SECONDARY TO (CARDIO EMBOLIC) ACUTE INFARCT IN PARITO TEMPORAL REGION.BED SORE AT SACRAL REGION (Grade III).
P:
Physiotherapy of right upper limb and lower limb
Chest physiotherapy
Inj.Levipil 500mg IV BD
Inj.Neomol 1gm iv if temp > 102f
Rt feeds 4th hrly milk 2nd hrly water
Inj.zofer 4mg iv tid
Inj.pan 40mg iv
Tab.met xl 12.5 mg/po/bd
Neb with mucomist 2nd hrly
Comments
Post a Comment