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
18/9/21
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
