75yr male Type-2Respiratory failure with respiratory acidosis with acute CVA Lf hemiparesis(3days),Intubated I/v/o poor GCS(E1V1M4) & Hypercapnia connected to ventilator in ACMV-Vc mode
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/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 inputs on the comment box is welcome."
I've 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.
Case:A 70 year old male construction labourer by occupation was bought to casualty in unconscious state.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 20days back and later developed sob and cough not associated with sputum for which patient got treated in local hospital and the symptoms subsided on medication. Patient complained of inability to move left arm and left leg 4days back and had fever 6hours back for which he was given p650. Patient became unconscious at 4pm and was brought here for further management and treatment.
patient is a known case of Asthma since 4 years and diagnosed denovo hypertension and is on telmisartan 40mg.
not a known case of diabetes epilepsy.
HISTORY OF PAST ILLNESS:
There is no history of EPILEPSY.
Treatment history:
patient is a known case of Asthma since 4 years and is on medication
K/c/o denovo hypertension and is on telmisartan 40mg.
ON EXAMINATION
VITALS on admission
TEMPERATURE - Afebrile
PULSE RATE - 92 bpm
BLOOD PRESSURE -
70/50 mmHg
RESPIRATORY RATE - 20 cpm
SPO2 - 66% @ RA
GRBS 238MG/DL
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BAE +
CENTRAL NERVOUS SYSTEM :
GCS-E0V1M0
INTUBATION DONE on 23/5/2022
As the patient is found unconscious and vitals were unstable
Pre intubation vitals
TEMPERATURE - Afebrile
PULSE RATE - 42 bpm
BLOOD PRESSURE -
70/50 mmHg
RESPIRATORY RATE - 20 cpm
P/a distended
SPO2 - 66% @ RA
GRBS 238MG/DL
Abg was sent and shown
pH 7.137
Pco2 68.2
Po2 111
Hco3 17.6
S02 95
As it is showing severe respiratory failure type2 with severe respiratory acidosis and hypercapnea patient was immediately intubated with 8.5mm ET TUBE And connected to ventilator with ACMV -VC mode
PEEP-5CM H2O
VT-450
RR-18
FIO2 100%
POST INTUBATION VITALS
PULSE RATE - 84bpm
BLOOD PRESSURE -
130/90 mmHg
RESPIRATORY RATE - 20 cpm
P/a distended
SPO2 - 96% @ RA
Post intubation Abg
pH 7.177
Pco2 55.7
Po2 176
Hco3 17
S02 99%with100fio2
INVESTIGATIONS
ECG 9:45pm
ECG12:10am
Abg pre intubation
Abg post intubation
Type-2Respiratory failure with respiratory acidosis with acute CVA Lf hemiparesis(3days),AKI?,Intubated I/v/o poor GCS(E1V1M4) & Hypercapnia connected to ventilator in ACMV-Vc mode
Treatment
1.RT FEEDS 100ML MILK+100ML WATER 2ND HOURLY
2.IVF NS @50ML/HR
3.INJ CEFTRIAXONE 1GM IV BD
4.INJ NORAD( 2AMP+46ML NS)@14ML/HR
5.INJ DOBUTAMINE (1AMP+45ML NS)@2ML /HR
6.STRICT I/0CHARTING
Comments