A 41YEAR OLD MALE WITH CORPULMONALE SECONDARY TO COPD

CHIEF COMPLAINTS:
C/o B/L pedal edema since 20days
C/o generalised swelling of body since 2days

C/o scrotal edema since 10days






HOPI:
Patient was apparently asymptomatic 20days back then he developed B/L pedal edema which was gradual in onset, pitting type 

Pt. also has h/o shortness of breath (on &off) Grade III, since 3years



{10days back Pt. developed swelling of the scrotum 5x5cm in size, which is progressed to the present size 10x8cm, associated with pain; for which he got admitted in GENERAL SURGERY on 15/02/2022. 



During course of management under the dept. of surgery, Pt. started developing generalised swelling of whole body since 2days and Mild SOB



As the pt. requires no sudden surgical intervention(after evaluation by the surgery dept.), the case is transferred to GENERAL MEDICINE on 17/02/2022 i/v/o above complaints and falling saturation levels}



Facial puffiness +

No h/o othopnoea/ PND

NO h/o fever/ headache/ vomitings

No h/o burning micturition/ decreased urine output



PAST HISTORY:

k/c/o Acute exacerbation of COPD, Pulmonary TB; (used ATT for 6months 1YEAR back)

Not a k/c/o DM, HTN, THYROID, EPILEPSY, CVA

(Pt. had a history of admission in hospital 1Year back i/v/o SOB)

H/o ?hydrocele surgery at a hospital near suryapet 20years back



GENERAL EXAMINATION:

Pt. is c/c/c, obese and well nourished

No pallor, icterus, clubbing, lymphadenopathy, cyanosis



(Vitals @ Admission:)

Temp - 98.6 F

PR-98bpm

BP - 120/80 mmHg

Spo2 - 98%.

RR - 19 CPM

GRBS-157 mg/dl


SYSTEMIC EXAMINATION:

CVS - S1 S2 +

RS - BAE +, CLEAR, 

         NVBS. 

P/A - soft, non tender, no organomegaly.


Today morning(18/02/2022) at around 5:00AM i/v/o severe respiratory acidosis not responding to non- invasive ventilation, patient was planned for elective intubation

-20G IV line was secured over Rt. Hand

-pre oxygenation was done for 5min.

-INJ. GLYCO 0.1MG IV

-INJ. MIDAZOLAM 1MG IV

-INJ. PROPOFOL 50MG IV

-INJ. ONDANSETRON 4MG IV

-INJ. SCOLINE 100MG IV given

  (Spo2- 100% ; PR- 100bpm)

Pt. was intubated with 7.5mm ET TUBE, fixed at 22 lipmark 

 B/L air entry equal @ 5AM

Pt. connected to ventilator 

Ventilator settings:

ACMV- VC MODE

FiO2- 80%

TV- 500ml

RR- 18cpm

PEEP- 5cm of H2O

Post- intubation vitals:

Bp- 100/60 mmhg

PR- 110bpm

SpO2- 99% with FiO2 80%

CVS- s1s2 +

RS- BAE + , wheeze + 


Pulmonology referral on 19/02/2022:




{On 18/02/2022 at 3:30pm Pt had bradycardia & asystole,6cycles of CPR done,Pt couldn’t be revived & declared dead at 4:03pm


Immediate cause of death :- Sepsis with MODS with Type-2 Respiratory failure


Antecedent cause of death :- RHF,COPD,Old PTB}


INVESTIGATIONS:

15/02/2022:

RBS- 157mg/dl

CUE: ALB ++

          PUS CELLS3-4

          SUGAR- NIL

CBP: Hb- 13 gm /dl

          Tlc- 7300 cells/cumm

           Plt-1.58 lakhs/cumm

APTT- 32 sec

PT- 16sec

INR- 1.11

BT/CT: 2min/ 4min 30sec

RFT:

Blood urea -25 mg/dl

Phosphorus- 3.1 mg/dl

Serum creatinine- 1 mg/dl

Uric acid - 8.1 mg/dl

Na/k/cl/ ca/P- 141/4.0/102/9.7/3.1

LFT:

TB- 0.72; DB- 0.20; AST- 21 ; ALT-19; ALP- 152; TP-6.2; A/G RATIO -1.45


18/02/2022:

CBP: Hb- 14.1 gm /dl

          Tlc- 8460 cells/cumm

           Plt-1.05 lakhs/cumm

RFT:

Blood urea -20mg/dl

Serum creatinine- 1.1 mg/dl

Uric acid - 10.6 mg/dl

Na/k/cl/ ca/P- 143/3.9/97/9.6/4.3

LFT:

TB- 1.36; DB- 0.33; AST- 31 ; ALT-19; ALP- 143; TP-6.0; A/G RATIO -1.26


19/02/2022:

HEMOGRAM: Hb- 14.8 gm /dl

                        Tlc- 15,400 cells/cumm

                        Plt-1.15 lakhs/cumm

RFT:

Blood urea -56mg/dl

Serum creatinine- 2.0 mg/dl

Uric acid - 7.4 mg/dl

Na/k/cl/ ca/P- 145/3.8/98/10/6.8


19/02/2022:

LFT:

TB- 2.68; DB- 0.45; AST- 234; ALT-58; ALP- 115; TP-6.6; A/G RATIO -1.02

RFT:

Blood urea -106mg/dl

Serum creatinine- 3.4 mg/dl

Uric acid - 12.9mg/dl

Na/k/cl/ ca/P- 147/4.3/98/9.6/2.2


FEVER CHART:


ABG:

(17/02/2022)- 3PM:


9:30 PM:


11 PM:
(18/02/2022)- 3:09 AM:(before intubation)


6:18 AM:( post intubation)


9:40 AM:

2:06 PM:

6:02 PM:

ABG: 19/02/2022(12:47 PM)

ECG: (15/02/2022)

17/02/2022(5:40AM)



CHEST X-RAY:(15/02/2022)



ET X-RAY POST INTUBATION:(17/02/2022)


19/02/2022:

2D ECHO:
Dilated RA/RV

D-shaped LV

IVC dilated

Mod- severe TR with PAH

Good LV systolic function 

EF- 62%

Diastolic dysfunction +


USG B/L INGUINOSCROTAL REGION:(23/04/2022)

-Minimal free fluid in Rt. Scrotal sac(Minimal Rt. Hydrocele)

DIAGNOSIS: 

CORPULMONALE SECONDARY TO COPD ; OLD PULMONARY TB, TYPE II REPSIRATORY FAILURE


P:

1.AIR/WATER BED

2.RYLE’S FEED- 100ML MILK WITH PROTEIN POWDER 2nd HOURLY; 50ML WATER HOURLY

3.INJ. LASIX 40MG IV BD

5.NEB. WITH DUOLIN 8th HOURLY; BUDECORT 12th HOURLY

6.DVT STOCKINGS 

7.FREQUENT CHANGE OF POSTURE 2nd HOURLY

8.INJ. MIDAZ IV INFUSION @ 3ML/HR

9.INJ. ATRACURIUM 2amp IN 45 ml NS @ 5ML/HR

10.ET AND ORAL SUCTION 2nd HOURLY 

11.STRICTLY I/O CHARTING

12.MONITOR VITALS


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