A 55 YEAR OLD MALE IN CARDIOGENIC SHOCK.

-
A 55 year old male pt, by occupation, r/o velimandu nalgonda came to the casualty with clo Sudden onset SOB ( Today 9:00PM) with Sweating 
pain and swelling of It Leg (since 3 days) 
pt had Binge of alcohal intake 2 days back then he
had 1 Episode of Vomiting> Non projectile, Non Bilious, contain food particles, Non foul smelling, From then pt is heavily decreased food intake,  pain & swelling of the left leg till knee, Not associated with any trauma
pt is having Soß (grade I-0) (since 1 year).
no orthopnea, PND .
 B/l Lower limb Edema (On and off) Relieves on taking medication.

* Problems the patient is having on 16/8/21
1- hypotension .
2- hypoxia 
3- left lower limb cellulitis .
4- COPD - emphysema - cor pulmonale .

HISTORY OF PAST ILLNESS: no h/o DM,HTN,Epilepsy,TB,,Asthma, fever ,loose stools,pain abdomen.
h/o similar complaints in the past.

PERSONAL HISTORY
DIET: mixed
Appetite: normal
Sleep:
Bowel and bladder movements:
Addictions
H/O Smoking and alcohol since 30 yrs.
Chronic smoker -18 beedis/day.
chronic alcoholic 90ml/ day.

Drug history
History of using ATT 1 year back for 2 months and discontinued

GENERAL EXAMINATION
pt is conscious, coherent, cooperative
afebrile, BP,PR - not recordable.
 SPO2 -65%,GRBS 99 Mg/dl, RR- 15CPM,
P/A: SOFT, NON TENDER, BOWEL SOUNDS PRESENT.

L/E: Edema present on lt lower limb, extending upto calf from toes.
loss of hair present, pain present on dorsiflexion of left foot, nails- brittle, skin over limb- shiny.
peripheral pulses - not recordable, not felt.
tenderness present on active as well as passive movements.
calf tenderness present .
no local rise of temp.
signs of vascular compromise +

SYSTEMIC EXAMINATION-
CVS- S1, S2 heard, no murmurs, no added sounds.
RS- BAE+,NVBS heard, trachea central in position.
P/A- soft, non-tender, no palpable mass or swelling.
CNS- NAD.

PROVISIONAL DIAGNOSIS-
HYPOVOLEMIC SHOCK

INVESTIGATIONS


* D dimer: 10ng/nl.

15/7/21






16/8/21

17/8/21

On the same day, Night
18/9/21




CLINICAL IMAGES
On 16/8/21
17/8/21
Aspirated fluid from bleb of left lower limb
 
ECCHYMOSIS on the ventral side of both elbows.

TREATMENT
14/8/21
Inj NOR AD @ 4ml/hr( increase or decrease with MAP) ( 36ml NS+ 4ml NOR AD)
INJ DOBUTAMINE @ 3.6ml/hr(45ml NS +5ml DOBUTAMINE)
Iv NS 4 IV stat bolus> 2NS @75ml /hr
THIAMINE in 100ml NS IV TID
GRBS 2nd hourly
Strict BP/PR/RR/TEMP/SPO2 charting.
STRICT I/O CHARTING.

15/8/21
Assessment: HYPOVOLEMIC SHOCK 2° TO LEFT LOWER LOBE PNEUMONIA, WITH LEFT LOWER LIMB CELLULITIS, COPD- COR PULMONALE.
BAE+, Wheeze+,left lower and mid zone Crepts+.
TREATMENT
IVF 1 NS @75ml/hr.
1 DNS @75ml/hr.
TAB AZITHROMYCIN 500 MG PO OD.
INJ AUGMENTIN 1.2 gm IV BD.
INJ NOR AD 12ml/hr >/< based on MAP( > 65mmhg)
INJ DOBUTAMINE@4.5 ml/hr >/< to maintain MAP.
Nebulisation with DUOLIN 4th hrly
BUDECORT 12 th hrly 
INJ HYDROCORTISONE 100 mg IV STAT.
Tab PAN 40mg PO OD.

16/8/21
SOAP NOTES 
 A  55 Year old male came with 
Hypovolemic shock 

Subjective : 
Decreased SOB 

Objective :
 Temp:98F
 PR:112 bpm
 RR: 20 cpm
 BP: 90/60 mmhg 

Assessment-
 HYPOVOLEMIC SHOCK secondary to dehydration WITH LEFT LOWERLIMB CELLULITIS
OLD KOCHS?

Plan of treatment - 
1) IVF  DNS ,NS @75ml / hr 
2)TAB AZITHROMYCIN 500mg/po/ od  
3)Inj AUGMENTIN 1.2 gm/IV/BD 
4) inj NORADRENALINE 
5) inj DOBUTAMINE @ 4.2ml/ hr 
6)NEB with DUOLIN 4 th hrly
                 BUDECORT 12th hrly
7) Tab PAN 40 mg 
8) inj OPTINEURON 1amp  in 100 ml NS /IV/Od 
9) hrly bp monitoring

SOAP NOTES Day 2 
A  55 Year old male with 
Hypovolemic shock 

Subjective : 
Lesions on left lower limb

Objective :
 Temp:98F
 PR:104 bpm
 RR: 20 cpm
 BP: 90/60 mmhg 

Assessment-
 HYPOVOLEMIC SHOCK secondary to dehydration
WITH LEFT LOWERLIMB CELLULITIS
?OLD KOCHS

Plan of treatment - 
1) Inj AUGMENTIN 1.2 gm/IV/BD
2)TAB AZITHROMYCIN 500mg/po/ od  
 D1 3)inj CLINDAMYCIN 600mg /iv/ bd 
4) inj NORADRENALINE 
5) inj DOBUTAMINE @ 4.2ml/ hr 
6)NEB with DUOLIN 4 th hrly
                 BUDECORT 12th hrly
7) Tab PAN 40 mg 
8)inj THIAMINE 200micrograms /im/TID 
9)inj OPTINEURON 1amp  in 100 ml NS /IV/Od 
10)tab CHYMEROL FORTE TID 5 days 
11. tab HIFENAC P BD 5 days 
12. Tab PREGABALIN 75mg 
13. NECOTEX LOZEN GEL 4mg

 SOAP NOTES DAY 4
A 55 Year old male with 
Hypovolemic shock 

Subjective : Ecchymosis over ventral side of both elbows.


Objective :
 Temp:98.5F
 PR:108 bpm
 RR: 21 cpm
 BP: 60/40 mmhg 
GRBS :150 mg/dl.
Spo2 100% on 4 l oxygen.

Assessment-
 HYPOVOLEMIC SHOCK secondary to dehydration
WITH LEFT LOWERLIMB CELLULITIS
OLD KOCHS?
With alcohol dependence syndrome
With tobacco dependence

Plan of treatment - 

*TAB AZITHROMYCIN 500mg/po/ od  
2)Inj AUGMENTIN 1.2 gm/IV/BD 
3) inj NORADRENALINE 6 ml/hr , increase or decrease based on MAP 
4) inj DOBUTAMINE @ 3ml/ hr .
5) Tab PAN 40 mg  
6) hrly bp monitoring
7)NEB with DUOLIN 4 th hrly
                 BUDECORT 12th hrly
8)inj THIAMINE 200micrograms /im/TID 
9)inj OPTINEURON 1amp  in 100 ml NS /IV/Od 
10)tab CHYMEROL FORTE TID 5 days 
11) tab HIFENAC P BD 5 days 
12)Tab PREGABALIN 75mg 
13) NICOTEX LOZEN GEL 4mg
14)Inj.CLEXANE 60mg S/c OD

Popular posts from this blog

A 75 YEAR OLD MALE WITH PYREXIA UNDER EVALUATION, ? CHRONIC BRONCHITIS ( PAST HISTORY OF TB)

-
Image
A 75 year old came to the casualty with c/o  fever, cold, cough since 4 days. patient was apparently asymptomatic till 2003 , then patient had B/L knee pain which gradually aggravated, then patient was started on NSAID'S daily for 3 years. Then in 2006- one day pt had continuous episodes of loose stools, 12-14 episodes per day with ? Anuria.  In view of anuria he went to nephrologist > ? AKI > Advised dialysis > patient underwent 1 session of hemodialysis. 2 YEARS BACK : pt experienced Polyuria , polydypsia for 2 days for which he visited nearby RMP and was diagnosed as DIABETIC and started on OHA. At present since 10 DAYS , patient had decrease of appetite, generalised weakness> took OHA and didn't take any food. Then Patient experienced 1 episode of hypoglycemia GRBS: 18 mg/dl ( frothing and uprolling of eyes). Then his attender gave him sugar water and 25 D Infusion in ambulance- Recovered. Had similar episode 2 days back. decrease in Appetite since 10 days. k/c/
Read more

It's a case of 18 yr old male patient , indicative of myopathy

-
Image
I have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  You can find the entire real patient clinical problem in this link here made by our interns https://hitesh116.blogspot.com/2020/05/12may-2020-elog-medicine-intern.html?m=1 After analysing the history, chief compliants, and investigations of the patient,  my review about the case is as follows. The patient had 1. Weakness in both LL since 20 days , which actually started 2 yrs back in the proximal limbs,  which was insidious in onset, gradually progressed to b/l distal regions. •H/o difficulty in squatting and getting up from that position, difficulty in wearing and holding chappals 2. BILATERAL non pitting type of edema Past history : No similar complaints in the past i.e. 2yrs back. No h/o DM, HTN,
Read more

A 35 year OLD FEMALE WITH HYPERTENSIVE URGENCY

-
Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. A 35 year old female r/o athmakuru came to the casualty for follow up i/v/o high bp. FIRST VISIT on 13/9/21 pt came with c/o fever a/w chills,cold,cough since 3 days( for which she consulted a local RMP, som
Read more