A 70 YEAR OLD FEMALE WITH CHEST PAIN AND SOB

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MEDICAL CASE

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:



ABG:Day1 at 7:20pm






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 1:00pm


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
ABG:Day3 at 6:40pm






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: 
https://youtu.be/Vy-dIqRsbkg
https://youtu.be/K42hUhYCP3E

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





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