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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

30 years old male occupation Working as farmer present to our casualty at 9:15 AM on 13/2/2022 with the chief complaint of dyspnoea since 2 hours and and nausea since 2 hours


HOPI :

Patient is the father of two girls is an alcoholic since past 5 to 6 years with a intake of 90 to 180 ML of whiskey every day .

yesterday night he consumed 90 ML of whiskey following which the patient complained of generalised weakness and two episodes of loose  stools .

At 4 AM in the morning patient was hungry so he was given milk when  he was in supine position by his attender (mother) Following which the patient started to complain of nausea and he become tachypneic

H/o Intake of herbal medication for one day For alcohol dependence syndrome 


Past history : 

Not a known case of DM, HTN,TB,epilepsy, CAD, CVA.


Personal history :

Diet : mixed

Appetite : normal

Bowel and bladder moments : regular

Habits/addictions : he Is alcoholic since six years daily intake of whiskey 90 to 180 ML per day.

He chews tobacco one pack for day.


Family history : 

No significant family history


Genral examination : 

Patient is conscious, coherent , cooperative

No signs of pallor , ictreus, clubbing , Sinuses lymphadenopathy , pedal edema.

                 





                              





Vitals : 

Temp : 

Bp : 190/90 MMHG

Pr :  120 bpm

Rr : 40 cpm

Spo2 : 60% at ra

Grbs : 210mg%


Systemic examination : 

Cardiovascular system : s1 , s2 heard , no murmur 

Respiratory system : b/L respiratory crepts in all lung fields.

Per abdomen : soft , non-tender , no organomegaly.


INVESTIGATIONS:

HEMOGRAM: 

HB: 17.9

TLC: 4,000

N/L/E/M/B: 85/10/01/04/00

PCV: 53.4

MCV: 90.1

MCH: 30.2

MCHC:33.5

RBC:5.93

PT:2.06

RDW-CV :12.8

RDW-SD: 42.5

PS: NC/NC


RFT:

BLOOD UREA : 21mg/dl

SERUM CREATININE: 0.8 mg/dl

SERUM ELECTROLYTES:

Ca : 9.6

Na+ : 144

K+: 4.0

Cl-: 100


LFT

TB: 1.44

DB: 0.65

SGOT:40

SGOT:15

ALP: 169

TP:7.3

ALBUMIN:3.6

A/G: 1.36


Rbs : 125


Serum osmolality : 302.4


Serology : negative 


Complete urine examination :

Albumin : 3+

Sugar : 2+


Ecg : 

            


    


     

Cxr :

           

 
Pre intubation x-ray



 Post intubation x-


 Treatment : 

1) head end elevation
2) inj.piptaz 2.25gm/iv/6th hrly
3) Nebuliaztions with mucomist 4th hrly and budecort 6th hrly
4) chest physiotherpay 12th hrly
5) inj.thiamine 1amp in 100ml Ns/iv/tid
6) monitor vitals hourly - bp,pr,spo2,rr
7) frequent suctioning of oral and nasal secretions 

On admission (13/2/22)

Post intubation 

14/2/22(8am)

14(4pm)

14(11pm)

15/2/22 , re-intubation (8pm)

15(9pm)

15(11pm)

PH

7.13

7.23

7.34

7.36

7.44

7.19

7.2

7.36

Pco2

61.7mmhg

48.5mmhg

37.5mmhg

41.7mmhg

37.5mmhg

76.6mmhg

52.4mmhg

45.2mmhg

Po2

87.5mmhg

250.7mmhg

101.5mmhg

57.7mmhg

176.5mmhg

46mmhg

137mmhg

75.6mmhg

Hco3

19.0mmol/l

20mmol/l

20.4mmol/l

22.3mmol/l

21.0mmol/l

28.7mmol/l

24.5mmol/l

25.1mmol/l

So2

87.4%

99.3%

85.3%

86.5%

97.3%

63.8%

97.1%

92.4%


16/2/22(2am)

16/2/22(6am)

16(7.30am)

16(6pm)

16(10pm)

17(2am)

17(6am)

17(3pm)

PH

7.27

7.19

7.31

7.43

7.36

7.43

7.39

7.36

Pco2

45.1mmhg

74.9mmhg

52.9mmhg

44.3mmhg

38.5mmhg

45.6mmhg

44.2mmhg

51.9mmhg

Po2

118mmhg

120mmhg

140mmhg

226.4mmhg

154mmhg

140.7mmhg

116mmhg

121mmhg

Hco3

25.9mmol/l

28.1mmol/l

25.9mmol/l

28mmol/l

22.9mmol/l

30.2mmol/l

26.2mmol/l

31.3mmol/l

So2

97.4%

96.1%

97.4%

85.6%

96.5%

87.3%

97.1%

97.3%


17(1.20pm)

17(4.00pm) 

17(10.15pm)

18(6.45am)

18(2.45pm)

18(7.40pm)

19(1.45pm)

At 3am (self extubated)

20(12.15am)

20(6.15am)

PH

7.39

7.43

7.51

7.44

7.23

7.39

7.48

7.42

7.45

Pco2

51.9mmhg

43.3mmhg

12.9mmhg

45.4mmhg

72.6mmhg

52.8mmhg

48.0mmhg

51.5mmhg

49.1mmhg

Po2

121mmhg

116mmhg

220mmhg

69.0mmhg

110mmhg

98.6mmhg

67.8mmhg

90.8mmhg

147mmhg

Hco3

31.3mmol/l

28.5mmol/l

10.3mmol/l

30.7mmol/l

29.6mmol/l

31.4mmol/l

35.0mmol/l

32.8mmol/l

30.2mmol/l

So2

97.2%

98.5%

96.2%

90.7%

95.0%

95.7%

91.9%

95.0%

97.4%


21(12am)

21(6am)

PH

7.41

7.40

Pco2

34.8

37.7

Po2

108

91.2

Hco3

21.9

23.1

So2

96.1

95.0




ICU
BED NO : 3

S: Sensorium improved responding to vocal commands 

O: morning patient was self extubated 
Spo2 maintaing 90% at room air.. frequent nebulisations given and suctioning was done.. giving chest physiotherapy at regular intervals
Pt c/c/c 
Temp: Afebrile
PR : 104 bpm
SPO2 : 98%
GRBS : 137mg%
BP: 100/60mmhg
CVS: S1S2 Heard
RS: BAE+
P/A: Soft , non-tender 


A: Type-2 resp failure secondary to resp fatigue / Toxin mediated ?ARDS , ? Aspiration pneumonia 

P : 
1) ivf - ns , rl @ 100ml/hr 
2) inj.piptaz-225gm/iv/qid
3) inj.zofer-4mg/iv/tid
4) nebulization with mucomist - 4th hrly and budecort-6th hrly
5) inj.thiamine 1amp in 100ml/ns/tid

daily dose given (midaz) - 70mg and 2mg loraz intermittently 



ICU 
BED NO : 3

S: patient was drowsy before intubation 

O: pt got reintubated due to the carbon dioxide retention as patient is drowsy 
O/E :
patient is sedated 
Temp: Afebrile
PR : 90 bpm
SPO2 : 98%
GRBS : 94 mg %
BP: 120/70 mm hg 
CVS: S1S2 Heard
RS: BAE+
P/A: Soft , non-tender 

SIMV Mode :
FiO2 -50%
PEEP- 6
VT- 320 


A: Type-2 resp failure secondary to resp fatigue / Toxin mediated ?ARDS , ? Aspiration pneumonia 

P : 
1) ivf - ns , rl @ 100ml/hr 
2) inj.piptaz-225gm/iv/qid
3) inj.zofer-4mg/iv/tid
4) nebulization with mucomist - 4th hrly and budecort-6th hrly
5) inj.thiamine 1amp in 100ml/ns/tid
6)INJ hydrocort 100mg /IV/ BD

daily dose given (midaz) - 70mg and daily dose given(fentanyl) - 200mcg , 2mg loraz intermittently

ICU 
BED NO -2
S-Patient was irritable since yesterday 7:30pm and later became drowsy I/V/O Type -2 respiratory failure and poor gcs patient was intubated at 8pm kept on mechanical ventilation.
H/o 10 episodes of loose stools yesterday(watery in consistency,not associated with pus/blood)
O: 
Pt c/c/c 
Temp: 99.5
PR : 85bpm
SPO2 : 98%
GRBS : 93mg%
BP: 140/70mmhg
CVS: S1S2 Heard
RS: BAE+
P/A: Soft , non-tender 

Ventilaor settings 
Mode acmv vc 
Rr:28 total,  setting12
Fio2 tapered from 100 to 50
I:E ratio 1:4

A: Type-2 resp failure secondary to resp fatigue / Toxin mediated ?ARDS , ? Aspiration pneumonia 

P : CO2 washout through ventilator.
1) ivf - ns , rl @ 100ml/hr 
2) inj.piptaz-225gm/iv/qid
3) inj.zofer-4mg/iv/tid
4) nebulization with mucomist - 4th hrly and budecort-6th hrly
5) inj.thiamine 1amp in 100ml/ns/tid.
6) Inj. Hydrocortisone 100 mg iv BD

daily dose given (midaz) - 70mg and daily dose given(fentanyl) - 400mcg , 2mg loraz intermittently
         
              
                        
X-ray chest taken on 16/2/22 at 8.00am



ICU 
BED NO -2
S-Patient is on mechanical ventilation 
O: 
On examination patient was adequately sedated.
Temp: 99.5
PR : 85bpm
SPO2 : 98%
GRBS : 93mg%
BP: 140/70mmhg
CVS: S1S2 Heard
RS: BAE+
P/A: Soft , non-tender 

Ventilaor settings 
Mode changed to acmv - cpap
Rr:28 total,  setting12
Fio2 tapered from 60 to 35 over a period of 6 hours 
I:E ratio 1:4

A: Type-2 resp failure secondary to resp fatigue / Toxin mediated ?ARDS , ? Aspiration pneumonia 

P : CO2 washout through ventilator.
1) ivf - ns , rl @ 100ml/hr 
2) inj.piptaz-225gm/iv/qid
3) inj.zofer-4mg/iv/tid
4) nebulization with mucomist - 4th hrly and budecort-6th hrly
5) inj.thiamine 1amp in 100ml/ns/tid.
6) Inj. Hydrocortisone 100 mg iv BD

daily dose given (midaz) - 70mg and daily dose given(fentanyl) - 400mcg , 2mg loraz intermittently


ICU 
BED NO -2
S-pt became conscious, coherent, cooperative. Obeying comments
Pt complaints of generalized body pains
C/o throat pain
Feeling thirsty And  hungry

O: 
Patient is concious, coherent, cooperative
Temp: 98.5
PR : 85bpm
SPO2 : 98% @2 litres of oxygen
GRBS : 116mg%
BP: 150/90mmhg
CVS: S1S2 Heard
RS: BAE+
P/A: Soft , non-tender 


A: Type-2 resp failure secondary(resolving) to resp fatigue / Toxin mediated ?ARDS , ?

P : 
1) ivf - ns , rl @ 100ml/hr 
2) inj.piptaz-225gm/iv/qid
3) inj.zofer-4mg/iv/tid
4) nebulization with mucomist - 4th hrly and budecort-6th hrly
5) inj.thiamine 1amp in 100ml/ns/tid.
6) Inj. Hydrocortisone 100 mg iv BD

daily dose given (midaz) - 70mg and daily dose given(fentanyl) - 400mcg , 2mg loraz intermittently



30y/M
ICU 
BED NO -3

S-pt became conscious, coherent, cooperative. Obeying comments,
Decreased generalized body pains
Feeling thirsty And  hungry

O: 
Patient is concious, coherent, cooperative
Temp: 98.5
PR : 85bpm
SPO2 : 97%
GRBS :116mg%
BP: 120/80mmhg
CVS: S1S2 Heard
RS: BAE+
P/A: Soft , non-tender 


A: Type-2 resp failure secondary(resolving) to resp fatigue / Toxin mediated ?ARDS ?

P : 
1) ivf - ns , rl @ 100ml/hr 
2)inj.zofer-4mg/iv/tid
3) nebulization with mucomist - 4th hrly and budecort-6th hrly
4)inj.thiamine 1amp in 100ml/ns/tid.
Remove ryles and starting oral feeds


30y/M
ICU 
BED NO -3

S-patient Obeying comments,
Decreased generalized body pains , pain in the throat 


O: 
Patient is concious, coherent, cooperative
Temp: 98.5
PR : 85bpm
SPO2 : 97% in RA
GRBS :116mg%
BP: 120/80mmhg
CVS: S1S2 Heard
RS: BAE+
P/A: Soft , non-tender 


A: Type-2 resp failure secondary(resolving) to resp fatigue / Toxin mediated ?ARDS ?

P : 
1) ivf - ns , rl @ 100ml/hr 
2)inj.zofer-4mg/iv/tid
3) nebulization with mucomist - 4th hrly and budecort-6th hrly
4)inj.thiamine 1amp in 100ml/ns/tid.
Remove ryles and starting oral feeds





            

           

              


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