A 47 yr old male with Shortness of breath and cough with sputum

12 December 2021

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Khushi Tulsyan

Roll no. 75

A 47 yr old male with chief complaints of Shortness of Breath and cough with sputum. 

A 47 yrs old male patient came with a chief complaints of shortness of breath and cough  with sputum since 4 days. 

HOPI-

Pt was apparently asymptomatic 15yrs back.Then he had intermittent SOB grade 2 associated with cough with mucoid  for which patient was on inhalers .

And also he was diagnosed with aasthma. 

3yrs back he had H/o  SOB grade 4 with orthopnea pedal edema, abdominal distension and after consulting cardiologist he was said to have a CAD treatment was initiated with tab fursomide. 

9 days back he had shortness of breath grade 4 orthopnea abdominal distension pedal edema and was admitted to an hospital outside and treatment was initiated (there he was diagnosed with BP and DM) but as there was no improvement in his condition he was shifted to our hospital 4 days back. 

He came in with oxygen cylinder on. 

Course of illness during hospital stay:

Patient presented with grade 4 SOB and because of no improvement and increased respiratory acidosis and hypercapnea he was mechanically ventilated. 

Patient is on mechanical ventilator since 2 days with fever spikes since yesterday and also had an VAP. 

Past History :

He was recently diagnosed with BP and DM

He had asthma since 15 yrs 

He is known case of CAD since 3 yrs. 

Not a k/c/o TB, CVD. 

Personal history :

Diet-mixed 

Appetite - normal 

B&B - Irregular

Sleep - Adequate

Addictions - Smoking since 20 yrs 3 cigs/ day. 

Alcohol occasionally since 20 yrs

And chews tobacco

Family  history -

Significant

His father and grandfather had aasthma. 

Physical Examination:

Patient is not conscious and is on ventilaton since 2 days. 

General:

Pallor absent

Incterus absent

Cyanosis 

Clubbing absent

Lymphadenopathy absent

Odema absent

Temp - febrile 

BP- 100/60 mmHg

Rr - 18cpm

PR- 94bpm

SpO2-93%

Grbs- 286mg/dl

Systemic:

CVS:

Cardiac sounds - S1+ S2 +

Respiratory:

Dysponea +

Position of trachea central

Breath sounds - vesicular

Abdomen:

No tenderness 

No palpable mass

CNS:

Patient is not consious and is on sedation, bronchodialtors and on mechanical ventialtior

Provisonal diagnosis:

Cor pulmonale with severe pulmonary hypertension with COPD and severe respiratory acidosis. 

Investigations:

1.Fever chart:

2.Co2 levels:

3a.ECG on day of admission:

3b.ECG as of today:

4.T3,T 4:

5.Blood Urea:

6.LDH:

7.LFt:

8.Serum creatinine:

9.Serum electrolytes:

10.Blood gas values:

11.Radiological:



Summary:

Treatment on 4 th day of his stay in hospital:

On inj vecuronium 4mg/hr,midazolam 2mg/hr and fentnyl 2 ml/hr infusion

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

And on antibiotics