58 male with sob and generalised weakness

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PRESENTING COMPLAINTS

58 MALE PATIENT PRESENTED SITH THE CHIEF COMPLAINTS OF SOB SINCE 15 DAYS AND C/O GENERALISED WEAKNESS SINCE 2 DAYS

HOPI: PATIENT WAS BROUGHT TO THE CASUALITY IN A DROWSY BUT AROUSABLE STATE.

PATIENT WAS APPARENTLY ALRIGHT 15 DAYS BACK THEN HE HAD FEVER WHICH IS LOW GRADE, GRADUALLY PROGRESSIVE ASSOCIATED WITH CHILLS AND RIGORS. COUGH WITH SPUTUM, SCANTY, WHITISH IN COLOUR, BLOOD TINGED SPUTUM (INTERMITTENT) WHICH IS RELIEVED AFTER TAKING MEDICATION.

SOB SINCE 15 DAYS GRADUALLY PROGRESSIVE FROM GRADE 2 TO GRADE 4 (NYHA). ORTHOPNEA +, NO DYSNEA. HIS SYMPTOMS GOT RELIEVED AFTER TAKING TREATMENT. GENERALISED WEAKNESS SINCE 2 DAYS AND SUDDEN ONSET SOB FOR WHICH HE WAS BROUGHT TO THR CASUALITY 

HISTORY OF PAST ILLNESS: 

SIMILAR COMPLAINTS IN THE PAST 4 YEARS BACK FOR WHICH HE GOT ADMITTED AND TREATED

K/C/O DM II SINCE 10 YEARS (ON UNKNOWN MEDICATION)

N/K/C/O HTN, TB, EPILEPSY, CVA, CAD

GENERAL EXAMINATION 

NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA

VITALS :

BP : 180/110

PR : 126

RR : 48 CPM 

TEMPERATURE : 99.2 F 

SPO2 : 83

GRBS : HIGH

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM : S1 S2 HEARD, NO MURMURS

RESPIRATORY SYSTEM : BAE + , NVBS

WHEEZE : YES

DYSPNEOA : YES

CREPTS PRESENT

ABDOMEN : SCAPHOID, NON TENDER

CENTRAL NERVOUS SYSTEM: DROSY BUT AROUSABLE

SPEECH: NO RESPONSE

NO SIGNS OF MENINGEAL IRRITATION

INVESTIGATIONS: 

PATIENT WAS ADMITTED OUTSIDE HOSPITAL AND WAS TREATED WITH INJ PIPTAZ AND INJ LEVOFLOX FOR 6 DAYS EVEN AFTER WHICH THE CONDITION HAS WORSENED. 

CT WAS DONE ON 26TH FEB 2023

ON 28/02/2023

ON 6/03/2023

BLOOD UREA : 210

SERUM CREATININE : 2.9

APTT : 34 SEC

PHOSPHORUS : 5.2

PT : 17 SEC

INR : 1.25

CALCIUM 9.5

SERUM FOR OSMOLALITY : 298

SERUM MAGNESIUM : 1.9

On 7/03/2023

On 08/03/2023

Sofa score - 11   40-50%mortality

qsofa score -3 

Curb 65 -4 points -higher risk need intensive care admission

Berlin criteria 

1.Acute insult with in one week 

2.Pao2/Fio2-

Mild less than 300 

Moderate -200-300

Severe -less than 200

3.chest x ray showing b/l pulmonary infiltrates 

4.exclude fluid overload and cardiogenic cause

Berlin criteria not satisfied

PATIENT INTUBATED AT 7.45 am ON 08/03/2023

PRE INTUBATION ABG

POST INTUBATION ABG

POST INTUBATION XRAY

DIAGNOSIS 

LEFT UPPER LOBE PNEUMONIA WITH CAVITARY LESION

 TYPE I RESPIRATORY FAILURE

AKI ON ? CKD 

WITH TYPE II DIABETES (WITH HYPERGLYCEMIA)

TREATMENT: 

1. INJ VANCOMYCIN 1 MG IV STAT FOLLOWED BY 600 MG IV OD

2. INJ PIPTAZ 4.5 GM IV STAT GIVEN FOLLOWED BY 2.25 GM IV TID

3. TAB. AZITHROMYCIN 500 MG OD 

4. NEB. IPRAVENT INH TID

    NEB. BUDECORT INH BD

5. INJ PANTOP 40 MG IV OD

6. IVF NS @ 100 ML/HR

7. STRICT I/O CHARTING

8. INTERMITTENT NIV SUPPORT 

9. INJ HAI (40 U + 38 ML / NS) @ 6 ML/HR

10. GRBS CHARTING HOURLY

11. PR / BP CHARTING HOURLY

12. TEMP CHARTING 4TH HOURLY

13. TAB. DOLO 600 MG SOS

14. INJ NEOMOL 18 GM IV SOS