History of presenting illness:
Patient was apparently asymptomatic 3 months back after which she developed SOB which was insidious in onset (grade 2 to 3 ), progressive in nature a/w Wheeze and orthopnea.
C/o cough since 10 days with expectoration (mucoid, minimal, foul smelling and not blood stained) increased on lying down and decreased when sitting down
- c/o fever since 7 days, insidious in onset a/w chills
- c/o decreased urine output since 2 days
- No c/o chest pain/ myalgias/ loss of taste or smell/ pnd.
- h/o TB 10 years back ( took ATT for 6 months )
- h/o similar complaints for the past 6 months (on inhalation since 10 days SOS )
- not a k/c/o DM/ HTN/ IHD.
- h/o biomass exposure for 25 years.
Patient was admitted under pulmonology department for the above complains initially where she was intubated ( on 17/12/21) and then was shifted to medicine on 19/12/21 icu i/v/o increased heart rate and 2D ECHO findings.
On 19/12/21 one whole Blood transfusion was done(2 FFP+ 1 PRBC)
2D ECHO findings:
ON 17/12/21
Mild LVH, moderate PAH with RVSP = 70 mmhg
Good LV systolic function and EF=60%
Diastolic dysfunction present and minimal PE
Dilated RA/RV and IVC.
ON 20/12/21
LAD territory akinetic and mild LV dysfunction (EF=45%)
Moderate TR and PAH (RVSP=65 MMHG)
Dilated RA/RV/IVC
Mild extent MR+
Mild AR +
Sclerosis AS+
Diastolic dysfunction present
General examination
Patient was consious and cooperative
No signs of pallor, cyanosis, clubbing, koilonychia, edema.
Vitals:
Temperature: afebrile
Pr: 120 bpm
Rr: 39cpm
Bp: 140/90 mmhg
Grbs: 141 mg/dl
RS: BAE+ B/L crepts heard at SSA, IAA,ICA,MA
Cvs: s1 and s2 heard
P/A : soft
Investigations on admission:
Hb: 12.3
Tlc: 24000
Plt. Count: 4.40
LFT:
TB: 1 54
DB: 0.40
AST: 48
ALT: 41
ALP: 351
TP: 7.5
ALB: 3.4
RFT:
UREA: 35
CREAT: 1.0
UA: 7.5
Ca2+ : 10.0
Na+ : 140
K+ : 3.7
Cl- : 92
K+ : 3.7
ABG:
PH: 7.32
PCO2: 119
PO2: 67.4
HCO3- : 60.0
St. HCO3- : 52.1
16/12/21
ABG:
PH: 7.34
PCO2: 94.6
PO2: 81.8
HCO3-: 50.3
St.HCO3- : 44.9
Hb: 9.6
Tlc: 14200
Plt count: 3.34
17/12/21:
Na+: 145
K+: 4.2
Cl-: 93
ABG:
PH: 7.35
PO2 : 84.9
PCO2: 77.7
HCO3-: 42.6
St. HCO3-: 38.3
Na+: 145
K+: 3.7
Cl-: 92
Urine for ketone bodies: negative
Blood urea : 29
Cretainine: 0.6
Ecg:
18/12/21
D dimer: 2650
LFT:
TB: 1.80
DB: 0.40
AST: 58
ALT: 20
ALP: 153
TP: 6.0
ALB: 2.8
Troponin: negative
Blood sugar: 87 (fbs)
CBP
Hb: 9.7
Tlc: 9200
Plt. Count: 2.45
Bt: 2 min
Ct: 4 min
Pt: 20 sec
Aptt: 39 sec
ABG:
PH: 7.50
PO2 : 55.4
PCO2: 27.6
HCO3-: 21.5
St. HCO3-: 24.2
Blood group : B positive
Xray 8 am
Ecg at 10 50am
Ecg at 7 20 pm
CT:
19/12/21
Hb: 9.2
Tlc: 13800
plt. Count: 1.57
RFT:
Urea: 44
Creatinine: 0.5
Uric acid: 2.0
Ca2+: 9.2
PO4-3: 2.5
Na+ : 143
K+: 3.5
Cl- : 98
Ecg at 5 30 am
Ecg at 10 50am
20/12/21
ABG:
PH: 7.45
PCO2: 46.8
PO2: 198
HCO3-: 32.6
St.HCO3-: 31.8
Ecg:
Provisional diagnosis:
Acute exacerbation of brochiectasis with type 2 Respiratory failiure with PAH with B/L fibrosis with post TB sequelae.
Treatment
1. INJ. PIPTAZ 4.5 GM IV TID
2. TAB. AZITHROMYCIN 500MG OD
3. INJ. HYDROCORT 100MG IV TID
4. INJ. LASIX 20MG IV BD if sbp more than 110 mmhg
5. O2 inhalation at 6 to 8 liters per min
6. NIV with BIPAP continuously with 2 hours gap after meals
7. Neb. With duolin 4th hourly and budecort 8th hourly and mucomist 2nd hourly
8. Syp. AROSTOZYME 2tbsp TID
9. Syp. ASCORYL 2 Tbsp TID
10. T. PCM 650MG SOS
11. Inj. PAN 40 mg IV BD
TREATMENT IN MEDICINE DEPARTMENT
1. 1 WHOLE BLOOD TRANSFUSION
2. INJ. MIDAXOLAM AT 6 MG/HR
3. INJ. PANTOP 40MG IV OD
4. INJ. PIPTAZ 4.5 GM IV TID
5. T. AZITHROMYCIN 500MG IV BD RT
6. INJ. HYDROCORT 100MG IV BD
7. INJ TRANEXA 500MG IV BD
8. INJ. VIT K 10MG IN 100ML NS IV STAT
9. T. SILDENAFIL 20MG RT TID
10. IVF NS RL AT 75 ML/HR
11. AIR/ WATER BED
12. INJ. VASOPRESSIN 1 AMP IN 50 ML NS AT 1.6 ML/ HR
13. INJ. CLINDAMYCIN 600 MG IV TID
14. ET SUCTUON + ORAL SUCTION HOURLY.
Soap notes 22/12/21
S - fever spikes+
O- Pt is on mechanical ventilation(intubated on 17/12/21)
Under sedation
Acmv vc mode fio2- 70
Peep- 4, vt- 360, RR- 18,I:E-1:2.3
Temp- 100f
Bp- 120/70mmhg on inj noradrenaline @5ml/hr
Inj vasopressin @0.5ml/hr
PR- 94bpm
RR- 18cpm
Spo2- 97% with fio2-60
Grbs- 160mg/dl
I/o- 1000ml/1100ml
Rs- bae+, inspiratory crepts + at infrascapular and inframammary area
Cvs -s1s2+
P/a - soft ,bs+
Cns - E1VtM1
Pupils - b/l reacting to light
Corneal present
Conjuctival - present
Dolls eye- present
A - acute exacerbation of copd with type 2 respiratory failure
Severe PAH type 2
Post pulmonary kochs sequale
Denovo HTN
Heart failure with preserved ejection fraction (ef-45%)
P- tapering the ionotropes dosage, stop sedation and check for response
Inj piptaz4.5gm iv tid
Inj clindamycin 600mg iv tid
Inj pantop 40mg iv od
Ivf NS RL @75ml/hr
Neb with ipravent 8thhrly
Budecort 8thhrly
Oral and et suction 2nd hrly
Chest physiotherapy
