87 yr male with Breathlessness

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PRESENTING COMPLAINTS:

C/O breathlessness since 3hrs.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3hrs back and while eating food patient collapsed and was taken to near by RMP doctor and i/v/o high BP, sub lingual NTG tablet was given, after that patient was concious and  I/v/o decreasing oxygen levels and gasping state patient was reffered to our hospital .

Intubation notes:

Patient attenders have been explained about the present condition (Aspiration pneumonia with type I Respiratory failure) and need for intubation (Arrythmias and sudden cardiac arrest). Consent was taken.

87yr old male patient came to casuality in gasping state with tachypnea and his saturation was 85% with 15lit O2

Pre intubation vitals-

BP- 130/80mmhg

PR- 150bpm

CVS-S1,S2 +

RS- BAE+, Diffuse crepitations +

SpO2- 85% with 15lit O2

P/A- soft 

After pre oxygenation for 3min, preintubation medication (2cc Midaz, 2cc Atracurium, 1cc Succinyl choline)was given and under direct vision on vocal cords Endotracheal tube (7.5mm) was placed and fixed at 22mm mark at angle of mouth. Position of tube was confirmed by  bilateral chest raise and auscultation of all areas of lungs and was connected to ventilator.

Post intubation vitals-

BP- 120/80mmhg

PR- 128bpm

CVS-S1,S2 +

RS- BAE+

SpO2- 100% with ACMV-VC mode on 60%fiO2

P/A- Soft

HISTORY OF PAST ILLNESS:

Patient had history of CVA 10yrs back (Left side upper and lower limb weakness,slurred speech)

K/C/O Hypertension since 15yrs (on medication-Clinidipine)

K/C/O Tuberculosis 35yrs back (took 6months treatment)

Not K/C/O DM,Epilesy,CAD

PERSONAL HISTORY:

Diet- Mixed 

Appetite- normal 

Sleep- Adequate 

Bowel and bladder movements- normal 

Addictions- Alcohol,Smoking 

FAMILY HISTORY: 

No significant family history 

GENERAL EXAMINATION:

Patient is poorly built (malnutrition)

No Pallor, Icterus, Clubbing,Cyanosis,Lymphadenopathy,Edema

Temperature- 97.7F(Afebrile)

BP- 130/80mmhg

PR- 142bpm

RR- 24cpm

SpO2- 87% at 15lit O2

GRBS- 238@ admission 

SYSTEMIC EXAMINATION :

Respiratory System: 

Upper Respiratory tract examination:

Nostrils- normal 

Nasal septum- no deviation 

No nasal polyps 

No Tonsils 

Posterior pharyngeal wall- normal 

Lower Respiratory tract examination:

Inspection:

Shape of the chest - Circular 

Movement of chest- appears to be equal on both sides

Trachea- appears to be in central position 

Apex beat- visible 

No scars and sinuses seen

Palpation:

Trachea- Slightly deviated to left 

Apex beat- Felt in left 5th ICS

Movement of chest is slightly reduced on left side 

No rib crowding 

Percussion:

                                     Right                         Left

Supra clavicular       Resonant                 Resonant 

Clavicular                  Resonant                  Resonant 

Infra clavicular           Resonant                 Dull 

Mammary                  Resonant                  Dull

Axillary                      Resonant                 Resonant 

Infra axillary              Resonant                 Resonant 

Supar scapular 

Inter Scapular  

Infra scapular 

Auscultation:

Normal vesicular breath sounds 

No wheeze 

CVS:

S1,S2 heard 

No murmurs 

CNS:

Patient was Drowsy 

                  Upper limb                            Lower limb

               Right             Left                   Right          Left

Tone:   Hypertonia   Hypertonia    Hypertonia Hypertonia   

Power:           5/5           5/5                      5/5              5/5

Reflexes:         Right             Left

Biceps              +                    +

Triceps            +                     +

Supinator         +                    +

Knee                +                   +

Ankle               +                    +

Plantar         Extension       Extension 

LAB INVESTIGATIONS:

CHEST X-RAY:

ECG:

2D ECHO: 

2D echo video

PROVISIONAL DIAGNOSIS:

Type I Respiratory failure ?COPD with 

Right Heart failure with? Paroxysmal SVT with hypertension;

Non oliguric AKI 

TREATMENT:

IV fluids NS@50ml/hr

RT feeds (50ml free water 2hrly,100ml milk 4hrly)

INJ. MagnexFort 1.5g IV/BD

INJ. Lasix infusion@10mg/hr

INJ. Clindamycin 600mg IV/BD

INJ. PAN 40mg IV/OD

INJ. Neomol 1g IV/SOS

Nebulisation with Duolin 8hrly & Budecort 12hrly

Tab. Ecosprin-AV PO/OD

Tab. METXL 25mg PO/OD

Frequent bed positioning 2hrly