47yrs old Male with SOB

 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's 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.

Chief complaints:

47 yr old male came to casualty with c/o SOB , cough with sputum since 4days .

HOPI-
Pt was apparently asymptomatic 15yrs back had intermittent SOB  grade 2 increased on lying down position associated with cough with sputum which is mucoid,minimal in amount for which pt was on intermittent inhalers used only for one month.

3yrs back had H/o pedal oedema , SOB (grade-4) with orthopnea , abdominal distension , consulted the cardiologist , said to have CAD , patient was on TAB.frusemide , TAB PAH(20 mg) , Echo shows : RA , RV dilated with EF 50%.Patient was on irregular medication for CAD and Right heart failure with PAH.

4days back had H/o pedal oedema , abdominal distension, SOB(grade-4), decreased response , not responding to deep stimuli . Admitted in outside hospital with SpO2 :80 @ RA, RR:38/min . Patient was put on Inj.NA & dobutamine , O2 inhalation & intermittent BiPAP , Inj. Zostrutum, Inj thiamine  

Past History :
Not a k/c/o HTN,DM,TB,  Epilepsy,CVD

Personal history :
Diet-mixed 
Appetite - normal 
B&B - regular 
SMOKING: Chronic smoker&Tobacco chewing
               Smokes Beedis:18/day since 30yrs
               Tobacco chewing:1packet/day
ALCOHOL:chronic alcoholic
       Consume daily 90ml/day after his regular work since 30 yrs

Family history -not significant

On Examination :
Patient is 
Afebrile 
BP- 90/60 mmHg
PR- 87bpm
SpO2-87%@RA

Systemic examination :

RESPIRATORY SYSTEM 

On inspection

Shape of chest:Barrel shaped chest
Position of trachea: midline
PALPATION:
Apical impulse--at midcalvicularline@left5th ICS
On Percussion:
Hyper resonance in areas of IAA,IMA,ISA
ON auscultation:
Crepts heard in IAA,IMA,ISA

P/A - soft , non tender , BS +
CNS - NAD
CVS-S1,S2 Heard,no murmurs
P2 is loud at left 2nd ICS
Investigations :
6/12/2021

Treatment history: 
1.Head end elevation 
2.O2 inhalation to maintain SpO2
3.Inj. Lasix 40mg IV/BD (if SBP
4.Inj. pantop 40mg IV /BD
5.Nebulisation with budecort -12th hrly , duolin -8th hrly .
6.Tab. metformin 500mg PO / BD 
7. I/O , temp monitoring 
8. Weight monitoring - daily 

SOAP notes :
DAY1
S- sob decreased 
Cough with sputum +
No fever spikes
Passed stools yesterday

O- pt is conscious,coherent 
Afebrile
PR 94/min
Bp 110/80 mmhg
RR 22 cpm
Spo2 96%
Cvs s1s2 +
Rs b/l air entry+,b/l basal crepts +
P/a soft, non tender
Grbs 174 mg/dl
I/o 1000/2000

pH -7.35----7.38----7.41----7.38
Pco2-131--110----117-----137
Po2---340---68.6--62.1---83.6
Hco3--70.5--64.4--74---80.2
St.hco3--61.9--56--66.2--72.3
O2 sat--99.4---92--90---95.2

A- Corpulmonale with type 3 pulmonary arterial hypertension 
Severe respiratory acidosis
bronchial asthma
Denovo diabetes 

P- NIV with bipap continously
Neb with duolin ,mucomist tid,Budecort bd
Chest physiotherapy
Inj Augmentin 1.2 g iv bd
Inj hai s/c tid according to grbs
Monitor vital
Treatment history: 
1.Head end elevation 
2.O2 inhalation to maintain SpO2
3.Inj. Lasix 40mg IV/BD (if SBP
4.Inj. pantop 40mg IV /BD
5.Nebulisation with budecort -12th hrly , duolin -8th hrly .
6.Tab. metformin 500mg PO / BD 
7. I/O , temp monitoring 
8. Weight monitoring - daily 

SOAP notes :
DAY1
S- sob decreased 
Cough with sputum +
No fever spikes
Passed stools yesterday

O- pt is conscious,coherent 
Afebrile
PR 94/min
Bp 110/80 mmhg
RR 22 cpm
Spo2 96%
Cvs s1s2 +
Rs b/l air entry+,b/l basal crepts +
P/a soft, non tender
Grbs 174 mg/dl
I/o 1000/2000

pH -7.35----7.38----7.41----7.38
Pco2-131--110----117-----137
Po2---340---68.6--62.1---83.6
Hco3--70.5--64.4--74---80.2
St.hco3--61.9--56--66.2--72.3
O2 sat--99.4---92--90---95.2

A- Corpulmonale with type 3 pulmonary arterial hypertension 
Severe respiratory acidosis
bronchial asthma
Denovo diabetes 

P- NIV with bipap continously
Neb with duolin ,mucomist tid,Budecort bd
Chest physiotherapy
Inj Augmentin 1.2 g iv bd
Inj hai s/c tid according to grbs
O- pt on mechanical ventilator
ACMV VC mode
Rr-18
Vt-400
Peep-5
Fio2-70%
On inj vecuronium 4mg/hr,midazolam 2mg/hr and fentnyl 2 ml/hr infusion 
Afebrile
PR 92/min
Bp 100/60 mmhg 
RR 18 cpm
Spo2 96%
Cvs s1s2 +
Rs b/l air entry +,b/l basal crepts+
P/a soft, non tender
Grade 1 bed sore +
Grbs 286 mg/dl
I/o 1700/900

A- Corpulmonale with type 3 pulmonary arterial hypertension 
With type 2 respiratory failure
Severe respiratory acidosis
With ?copd
Denovo diabetes with grade 1 bed sore
P- Neb with duolin ,mucomist tid,Budecort bd
Frequent Et and oral suction 
Chest physiotherapy
Frequent change of position
Inj meropenem 1 g iv bd
Inj hai s/c tid according to grbs
Rt feeds 4th hrly
Monitor vitals
I/o charting

He was ventilated for 3 more days....with his saturation maintaining 99%
Then on 17/12/2021 morning there is sudden fall of his saturation and landed with cytokinestrom and at last he deid around 7.30AM

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