35 yr old man presented with shortness of breath


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 patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

Here is a case i have seen:
35 years male  Daily wage labourer, married 10 yrs back ,has 2 sons (9yrs,7yrs) used to drink 90 ml /day started at the age of 20yrs , stopped 3yrs back (bcoz of his wife) . Again started from 4 months daily bcoz of his friends (90ml/day).
10 days back he went to a function ,got drunk  and had a fall from bike (no h/o loc, vomitings,bleed from ears ,nose; headache, dizziness.) Injury to lateral side of leg by bike silencer 5 x3 cms ulcer .Got treated symptomatically for pain and ulcer dressings in their local area. Yesterday morning 2.00am he went to urinate,but he was not able to pass the urine , developed shortness of breath, orthopnea+, went to nearby hospital ,got relieved for sometime on oxygen therapy.Later he was referred to our hospital. Pt is k/c/o Asthma (on inhaler) from 6months.
Not a k/c/o Dm2/HTN/TB/Epilepsy/CAD
NO H/O Fever,cough, vomitings,loose stools,pedal edema,chestpain, palpitations.
No h/o past surgeries.
On examination:
Patient was conscious, coherent and cooperative.
Vitals:
Patient is afebrile
Respiratory rate: Tachypneic 35 cpm 
Bp: non recordable and immediately started on with dobutamine @4ml / hr. 
CVS: S1, S2 heard, no murmurs
Respiratory system: 
Bilateral diffuse crepitations heard. 
Per abdomen:
Soft, non tender
Bowel sounds heard
CNS: GCS: E4V5M6
     No abnormality detected. 
Patient suddenly went to cardiac arrest at 5:30 am  Emergency resuscitation done but patient died due to cardiopulmonary arrest with reduced ejection fraction( EF- 40%).
Investigations 


diagnosis : Heart failure with decreased ejection fraction
Treatment 
Inj dobutamine IV infusion at the rate of 4 ml / min
Inj noradrenaline IV infusion at the rate of 6 ml /min 
Inj piptaz 4.5 gm iv stat
Inj pan 40 mg IV BD 
Inj lasix 40 mg IV if SBP is greater than 120 mm hg
BP,PR ,RR ,SPO2 monitored hourly

Popular posts from this blog

Image
 34yr old man , as a working driver presented  with difficulty in swallowing since 5am   Weakness in Right UL and LL since 5am   Deviation of mouth to left since 5 am  Slurred speech since 6am .  Pt developed sudden onset of  difficulty in swallowing while he tried drinking water followed by he suddenly developed weakness of rt upper limb and rt lower limb .  His attendant later observed deviation of mouth towards left side and slurring of speech.  H/o 1episode of GTCS 3years back though wt on treatment.  He has been an occasionally  alcoholic since 20years .  Not a k/c/o Htn ,Dm type2, Thyroid disorder,  Asthama.  No h/o any past surgeries.   On examination:  Patient was conscious coherent and cooperative.   Vitals:    Pulse : 108 bpm  Respiratort rate: 18 cpm  Temperature: 98.6 F  Blood pressure: 170/100 mm hg  Grbs-153 mg/dl  Spo2: 98% at room ai...
Read more

bimonthly assessment january

Image
1.26 year old woman with complaints of altered sensorium since day,headache since 8 days,fever and vomitings since 4 days https://harikachindam7.blogspot.com/2020/12/26-year-old-female-with-complaints-of.html a. A 26 year old woman with complaints of Headache since 8 days Fever since 4 days Vomitings since 4 days Altered sensorium since 1 day 28 year old woman with 1. Hyponatremia secondary to SIADH 2. Tubercular meningitis 3. Acute infarct in the left thalamic region 4. SLE with multiple joint pains              b.      Hyponatremia Tb meningitis SLE  Sequence of events Tubercular   meningitis (TBM) is a rare condition in patients with systemic lupus erythematosus (SLE). The aim of this study is to describe the clinical characteristics, possible risk factors, and outcomes of SLE patients with TBM. On systematically reviewing medical records from10 SLE patients with TBM admitted to a hospital from December 2008 to December 201...
Read more