A 41Year old Male with CORPULMONALE secondary to COPD
C/o generalised swelling of body since 2days
C/o scrotal edema since 10days
Patient was apparently asymptomatic 20days back then he developed B/L pedal edema which was gradual in onset, pitting type
Pt. also has h/o shortness of breath (on &off) Grade III, since 3years
{10days back Pt. developed swelling of the scrotum 5x5cm in size, which is progressed to the present size 10x8cm, associated with pain; for which he got admitted in GENERAL SURGERY on 23/04/2022.
During course of management under the dept. of surgery, Pt. started developing generalised swelling of whole body since 2days and Mild SOB
As the pt. requires no sudden surgical intervention(after evaluation by the surgery dept.), the case is transferred to GENERAL MEDICINE on 25/04/2022 i/v/o above complaints and falling saturation levels}
Facial puffiness +
No h/o orthopnoea/ PND
NO h/o fever/ headache/ vomitings
No h/o burning micturition/ decreased urine output
PAST HISTORY:
k/c/o Acute exacerbation of COPD, Pulmonary TB; (used ATT for 6months 1YEAR back)
Not a k/c/o DM, HTN, THYROID, EPILEPSY, CVA
(Pt. had a history of admission in hospital 1Year back i/v/o SOB)
H/o ?hydrocele surgery at a hospital near suryapet 20years back
GENERAL EXAMINATION:
Pt. is c/c/c, obese and well nourished
No pallor, icterus, clubbing, lymphadenopathy, cyanosis
Temp - 98.6 F
PR-98bpm
BP - 120/80 mmHg
Spo2 - 98%.
RR - 19 CPM
GRBS-157 mg/dl
SYSTEMIC EXAMINATION:
CVS - S1 S2 +
RS - BAE +, CLEAR,
NVBS.
P/A - soft, non tender, no organomegaly.
Today morning(26/04/2022) at around 5:00AM i/v/o severe respiratory acidosis not responding to non- invasive ventilation, patient was planned for elective intubation
-20G IV line was secured over Rt. Hand
-pre oxygenation was done for 5min.
-INJ. GLYCO 0.1MG IV
-INJ. MIDAZOLAM 1MG IV
-INJ. PROPOFOL 50MG IV
-INJ. ONDANSETRON 4MG IV
-INJ. SCOLINE 100MG IV given
(Spo2- 100% ; PR- 100bpm)
Pt. was intubated with 7.5mm ET TUBE, fixed at 22 lipmark
B/L air entry equal @ 5AM
Pt. connected to ventilator
Ventilator settings:
ACMV- VC MODE
FiO2- 80%
TV- 500ml
RR- 18cpm
PEEP- 5cm of H2O
Post- intubation vitals:
Bp- 100/60 mmhg
PR- 110bpm
SpO2- 99% with FiO2 80%
CVS- s1s2 +
RS- BAE + , wheeze +
Pulmonology referral on 27/04/2022:
Immediate cause of death :- Sepsis with MODS with Type-2 Respiratory failure
Antecedent cause of death :- RHF,COPD,Old PTB}
INVESTIGATIONS:
23/04/2022:
RBS- 157mg/dl
CUE: ALB ++
PUS CELLS 3-4
SUGAR- NIL
CBP: Hb- 13 gm /dl
Tlc- 7300 cells/cumm
Plt-1.58 lakhs/cumm
APTT- 32 sec
PT- 16sec
INR- 1.11
BT/CT: 2min/ 4min 30sec
RFT:
Blood urea -25 mg/dl
Phosphorus- 3.1 mg/dl
Serum creatinine- 1 mg/dl
Uric acid - 8.1 mg/dl
Na/k/cl/ ca/P- 141/4.0/102/9.7/3.1
LFT:
TB- 0.72; DB- 0.20; AST- 21 ; ALT-19; ALP- 152; TP-6.2; A/G RATIO -1.45
26/04/2022:
CBP: Hb- 14.1 gm /dl
Tlc- 8460 cells/cumm
Plt-1.05 lakhs/cumm
RFT:
Blood urea -20mg/dl
Serum creatinine- 1.1 mg/dl
Uric acid - 10.6 mg/dl
Na/k/cl/ ca/P- 143/3.9/97/9.6/4.3
LFT:
TB- 1.36; DB- 0.33; AST- 31 ; ALT-19; ALP- 143; TP-6.0; A/G RATIO -1.26
27/04/2022:
HEMOGRAM: Hb- 14.8 gm /dl
Tlc- 15,400 cells/cumm
Plt-1.15 lakhs/cumm
RFT:
Blood urea -56mg/dl
Serum creatinine- 2.0 mg/dl
Uric acid - 7.4 mg/dl
Na/k/cl/ ca/P- 145/3.8/98/10/6.8
28/04/2022:
LFT:
TB- 2.68; DB- 0.45; AST- 234; ALT-58; ALP- 115; TP-6.6; A/G RATIO -1.02
RFT:
Blood urea -106mg/dl
Serum creatinine- 3.4 mg/dl
Uric acid - 12.9mg/dl
Na/k/cl/ ca/P- 147/4.3/98/9.6/2.2
FEVER CHART:
ABG:
(25/04/2022)- 3PM:
9:30 PM:
26/04/2022(5:40AM)
ET X-RAY POST INTUBATION:(26/04/2022)
D-shaped LV
IVC dilated
Mod- severe TR with PAH
Good LV systolic function
EF- 62%
Diastolic dysfunction +
USG B/L INGUINOSCROTAL REGION:(23/04/2022)
-Minimal free fluid in Rt. Scrotal sac(Minimal Rt. Hydrocele)
DIAGNOSIS:
CORPULMONALE SECONDARY TO COPD ; OLD PULMONARY TB, TYPE II REPSIRATORY FAILURE
Icu-2nd bed
List of complaints:- treatment given
1)SOB —->NIV
2)Anasarca——-> pre load reduction drugs(LASIX given)
3)Co2 narcosis——>Intubated & connected to mechanical ventilator
SOAP NOTES DAY1:
26/04/22:
S: -
O:
pt. on Mechanical ventilation under sedation
GCS- E1VTM1
Temp - 98.2F
PR- 110bpm
BP - 100/60mmHg
Spo2 - 94%
GRBS-119mg/dl
Mode: ACMV- VC
TV- 500ml
RR- 18cpm
FiO2- 80%
PEEP- 5cms of H2O
Systemic Examination :
CVS - S1 S2 +
RS - BAE +
P/A - soft
A:
RHF- COR PULMONALE SECONDARY TO COPD; OLD PULMONARY TB; TYPE II RESPIRATORY FAILURE ,INTUBATED ON 26/4/2022,POST CPR STATUS(1cycle)
P:
1.AIR/WATER BED
2.RYLE’S FEED- 100ML MILK WITH PROTEIN POWDER 2nd HOURLY; 50ML WATER HOURLY
3.INJ. LASIX 40MG IV BD
5.NEB. WITH DUOLIN 8th HOURLY; BUDECORT 12th HOURLY
6.DVT STOCKINGS
7.FREQUENT CHANGE OF POSTURE 2nd HOURLY
8.INJ. MIDAZ IV INFUSION @ 3ML/HR
9.INJ. ATRACURIUM 2amp IN 45 ml NS @ 5ML/HR
10.ET AND ORAL SUCTION 2nd HOURLY
11.STRICTLY I/O CHARTING
12.MONITOR VITALS
SOAP NOTES DAY2:
27/04/22:
S: -2 FEVER SPIKES 101F at 9:30pm and 2am
O:
pt. on Mechanical ventilation under sedation
GCS- E1VTM1
Temp - 98.2F
PR- 120bpm
BP - 120/90mmHg
Spo2 - 94%
GRBS-120mg/dl
Mode: ACMV- VC
TV- 500ml
RR- 18cpm
FiO2- 80%
PEEP- 5cms of H2O
Systemic Examination :
CVS - S1 S2 +
RS - BAE +
P/A - soft
A:
RHF- COR PULMONALE SECONDARY TO COPD; OLD PULMONARY TB; TYPE II RESPIRATORY FAILURE ,INTUBATED ON 26/4/2022,POST CPR STATUS(1cycle)
P:
1.AIR/WATER BED
2.RYLE’S FEED- 100ML MILK WITH PROTEIN POWDER 2nd HOURLY; 50ML WATER HOURLY
3.INJ. LASIX 40MG IV BD
5.NEB. WITH DUOLIN 8th HOURLY; BUDECORT 12th HOURLY
6.DVT STOCKINGS
7.FREQUENT CHANGE OF POSTURE 2nd HOURLY
8.INJ. MIDAZ IV INFUSION @ 3ML/HR
9.INJ. ATRACURIUM 2amp IN 45 ml NS @ 5ML/HR
10.ET AND ORAL SUCTION 2nd HOURLY
11.STRICTLY I/O CHARTING
12.MONITOR VITALS
13.inj hydrocortisone 100mg iv bd
14.tab. pah 20mg po tid
SOAP NOTES DAY3
ICU BED NO. 2
28/04/22:
S: - Fever spikes since yesterday evening(high grade fever)
O:
pt. on Mechanical ventilation under sedation
GCS- E1VTM1
Temp - 104F
PR- 130bpm
BP - 110/80mmHg
Spo2 - 94%
Mode: ACMV- VC
TV- 500ml
RR- 18cpm
FiO2- 100%
PEEP- 6cms of H2O
Systemic Examination :
CVS - S1 S2 +
RS - BAE +
P/A - soft
A:
RHF- COR PULMONALE SECONDARY TO COPD; OLD PULMONARY TB; TYPE II RESPIRATORY FAILURE ,INTUBATED ON 26/4/2022,POST CPR STATUS(1cycle)
P:
AIR/WATER BED
DVT STOCKINGS
RYLE’S FEED- 100ML MILK WITH PROTEIN POWDER 2nd HOURLY; 50ML WATER HOURLY
INJ. PIPTAZ 4.5GM IV TID
INJ. LEVOFLOX 750 MG IV OD
INJ. RANTAC 50MG IV OD
INJ. LASIX 40MG IV BD
FREQUENT CHANGE OF POSTURE 2nd HOURLY
INJ. VECURONIUM 1amp. IN 48ml NS 10ml/hr
INJ. DEXMEDITOMEDINE 25mcg in 50ML NS at 10ML/HR
ET AND ORAL SUCTION 2nd HOURLY
STRICTLY I/O CHARTING
MONITOR VITALS
INJ. HYDROCORTISONE 100MG IV BD
INJ. NEOMOL 1GM in 100ML IV SOS(if temp>101F)
TEPID SPONGING AND COLD SALINE PACKS