75yr male on mechanical ventilator

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CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever.

PRESENTING ILLNESS:

Patient was brought to casuality in unconscious state with GCS-E1V1M1

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 1day back, then he developed breathlessness and he went to local RMP doctor after 18hrs for which he was kept on nebulisation and his BP was 200/100mmhg (Telma40mg was given) and was reffered to our hospital.Patient was brought to our hospital in unconscious state, on examination central pulses are feeble, BP not recordable, Pupils were dilated and fixed. CPR was started and patient was revived after 10min CPR and connected to mechanical ventilator.

CPR and INTUBATION NOTES:

75yr male patient was brought to the casuality in unconscious state with GCS-E1V1M1, BP not recordable, i/v/o absent heart rate CPR was initiated according to AHA 2020 guidelines 

8:20am- BP, Pulse rate Not recordable 1mg adrenaline given and CPR continued 

8:25am- BP, Pulse rate Not recordable 1mg adrenaline given and CPR continued 

@8:26am- ROSC was achieved after 10min of CPR 

At 8:26am patient was intubated with 7.0 size ET tube under direct vision of light and ET tube was fixed at 21cm near angle of mouth. Position of tube was confirmed by bilateral chest raise and auscultation of all areas of lungs and was connected to mechanical ventilator 

Mode- ACMV-VC

RR- 18cpm

VT- 400ml

FiO2- 100%

PEEP- 7cm H2O

Post Intubation vitals:

GCS- E1V1M1

PR- 102bpm

BP- 140/100mmhg

CVS- S1,S2 +

RS- BAE+, NVBS

P/A- soft

SpO2- 96% with FiO2 100% on ACMV-VC mode

HISTORY OF PAST ILLNESS:

Not K/C/O HTN,DM,CAD,TB,Asthma 

PERSONAL HISTORY:

Diet- Mixed

Appetite- Normal 

Sleep- Adequate 

Bowel and Bladder- Regular 

ADDICTIONS:

Alcohol- Regular, since 40yrs

Tobacco- smoking since 40yrs 

FAMILY HISTORY:

No significant family history 

GENERAL EXAMINATION:

Patient is moderately built 

No pallor, icterus, clubbing, cyanosis, lymphadenopathy

B/L pedal edema- present

Vitals:

Temperature- 97.8F 

BP- 150/70mmhg

PR- 96bpm

RR- 18cpm

SpO2- 96%@ room air 

GRBS- 168mg/dl @ admission 

Per Abdomen:

Inspection:- no scars seen.

Palpation:- No tenderness 

Percussion:- No free fluid.

Auscultation:- Bowel sounds heard.

SYSTEMIC EXAMINATION:

CVS:

S1,S2 heard 

No murmurs 

RESPIRATORY SYSTEM:

BAE+

Position of trachea- central 

NVBS

No added sounds 

CNS:

Patient is unconscious

GCS- E1V1M1

Reflexes:    

                     Right                 Left

Biceps              —                    —

Triceps            —                     —

Supinator         —                    —

Knee                —                   —

Ankle               —                    —

Plantar         Mute              Mute

ECG:

2d-echo:

Chest X-ray:

MRI:

LAB INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

Post CPR status- ROSC

Cardiogenic shock (secondary to NSTEMI resolving);

Pre- Renal AKI (Non- Oliguric);

Heart Failure secondary to NSTEMI;

Type-I Respiratory failure;

Denovo Diabetes Mellitus 

TREATMENT:

RT feeding 4hrly(100ml free water, 50ml milk with 2 teaspoons of protein powder)

INJ. LASIX 40mg IV/BD

INJ. HAI s/c TID (according to GRBS)

INJ. Heparin 5000IU IV/QID

TAB. ECOSPRIN 75mg RT/OD

TAB. CLOPIDOGREL 75mg RT/OD

TAB. ATORVAS 40mg RT/OD

TAB. MET-XL 50mg RT/OD

INJ. Neomol 1gm IV/SOS

Air Bed

Frequent position change 2hrly

Monitor vitals