45 M with shortness of breath since two years

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Case presentation:

History is taken  from patient's wife as patient is not able to talk. 

A 45 year old male, auto driver by occupation complaints of sudden onset of shortness of breath post dialysis(2/10/2020) since 3 am on 3/10/2020.

Patient was apparently asymptomatic 3 years back when one day around 6pm he met with road traffic accident and had fracture of right lower limb. For the fracture rod (Nailing and plating) was inserted.He was incidentally found to have subclinical hypothyroidism with TSH being high than normal range and T3, T4 being normal and creatinine being 1.9 and then he was on Tab. thyronorm 25 mg for about 2 months and stopped it as he was subjectively feeling better.After which for about a year he took rest and later for 6 months he worked as a tractor driver without any complaints with total normal lifestyle. Then 1 and half  year back he went to a local hospital near their residence with complaints of shortness of breath(grade 3),cough,palpitations. Patient's wife gives history that he used to wake up from his sleep and sits and after a few minutes it used to subside. And after a few days his shortness of breath is aggravated on lying down and decreases while in sitting position.It was dry cough & No aggravating and relieving factors. There  the patient underwent few tests and found ser.creatinine being 3.25 and also was diagnosed with dilated cardiac myopathy with reduced ejection fraction from  60% to 40% and he was given medication (unknown). And at the same time patient was diagnosed with hypertension (he was on tab. Amlong 10) They were also told that patient has kidney infection and can become better with medication (unknown).There after he stopped driving tractor and bought an auto and worked as driver for 1 year. Patient was on regular medication but 8 months back because of financial crisis and he stopped taking medication for 2 months. And after 1 month he started losing his appetite and also associated with loss of around 10 kg of weight.patient has no history of night sweats . After that when he was again attacked with shortness of breath,one and half month back they came to Kamineni hospital where the patient was told his kidneys are malfunctioning and asked to get dialysis through AV fistula. For this reason they went to Hyderabad. After 5 days he again came to Kamineni hospital for further evaluation. Patient was diagnosed with asthma 1 year back (uses inhaler whenever necessary).

He had his first dialysis on 9/9/2020. And had his last dialysis on 3/10/2020.

Patient had three sessions of dialysis thereafter on 6/10/2020, 9/10/2020,12/10/2020

Not a k/c/o diabetes, tuberculosis,seizures, CVA, CAD. 

Patient was on mixed diet, eats only twice daily once in the morning around 10 am and then at night around 8 pm. He goes to work after having his breakfast and returns home by 7:30 pm. Patient usually sleeps around 10 for a minimum of 5-6 hours. Patient started consuming alcohol since 25 years of age. He consumes about 90 ml of alcohol daily. Not a smoker. He was married twice. He married his late wife 20 years back and had two sons with her. Later she was diagnosed with leukemia and died because of it. Later he married his current wife (informant) 8 years ago. He had a son with her. Patient has no sleep disturbances and his bowel movements were regular.

In view of falling saturation patient was intubated.

At around 8:30 am in view of falling heart rate CPR was started immediately according to 2015 AHA guidelines.Inj.Adrenaline 1 mg IV stat given. BP and PR normal. Another dose of Inj. adrenaline given after 5 min. Pulse rate recordable and ROSC established. Pink sputum is present.

O/E:

Patient is under conscious

Vitals:

BP-150/90 mm Hg taken in supine position in right arm 

PR-107 bpm 

Spo2-100% on ventilation

CVS: S1, S2 heard, no murmurs

Jugular venous pulsations are visible

RS: BAE +, fine creptiations are heard in B/L infra clavicular and B/L infrascapular areas. 

P/A:soft, non tender,  no organomegaly, bowel sounds +

Patient may have CKD with MHD with pulmonary edema secondary to hypertensive urgency and ROSC with T1 respiratory failure



Investigations:





Old reports:




























USG:










3/10/2020

Investigations 



Rx:
Inj.Midazolam o.1 mg/kg/hr
Inj. Dexmeditomidine 5ml/hr
Inj. Pan 40 mg/IV/OD
RT feeds 2nd hrly-200 ml milk
Inj.Lasix 40 mg IV TID
Tab.Nicardia 10 mg/PO/BD
PR, BP, RR hourly monitoring
GRBS-6th hourly
Neb with Budecort-12th hourly&
Mucomist-8th hourly



4/10/2020    
PR:139 bpm 
RR:25 cpm              
Spo2:99%                           
BP:160/100 mm hg taken in supine position in right arm
CVS:S1,S2 heard, no murmurs
RS: BAE+, crepts+ in infraclavicular areas

Rx
Head end elevation
oxygen inhalation
Inj. Pan 40 mg/IV/OD
Inj. Losix 40 mg/IV/TID
Tab. Nicardia 10 mg /PO/QID
RT feeds 2nd hourly with milk
NEB with Duolin-6th hrly
Mucomist-8th hrly 
Budecort-8th hrly

Patient is extubated in the evening and is on Oxygen.



5/10/2020

GCS-15/15
BP:160/100 mm hg taken in supine position in right arm
PR:123 bpm 
RR:20 cpm 
Spo2:99%

Investigations:

2D echo



Rx:

Fluid retention <1.5 lit/day
Salt restriction <2.5 gm/day
Head end elevation
Tab. Nicardia Ritard PO/BD
Tab. Lasix 40 mg PO/BD
Tab. Met -XL 25 mg PO/OD
Neb with Duolin -8th hrly
Mucomist-8th hrly
Budecort-12th hrly
Oxygen inhalation-6 lit/min
Strict BP charting
Temp/PR/RR/Spo2 monitoring
Inj. Augmentin 600 mg/IV/ OD




6/10/2020
BP:160/100 mm hg 
PR:116 bpm 

C/o cough with sputum with fever spikes

Investigations

Rx:

Intermittent CPAP is given
Head end elevation
fluid restriction <1.5 lit /day
Salt restriction <2 gm /day
Tab. Nicardia Retard 20 mg /PO/TID
Tab. Lasix 20 mg PO/BD
Inj.Augmentin 600 mg/IV/OD
NEB with Duolin -8th hrly,
 With Mucomist-8th hrly &
With Budecort -12th hrly
Temp/Bp/PR/Spo2/GRBS monitoring
BP charting hrly
Inj. Pan 40 mg/IV/OD
Tab. PCM 650mg/PO/TID
Inj. Ceftazidime 1gm IV stat







As the Hb level is 5.9 the patient had undergone blood transfusion on 6/10/2020

7/10/2020

Bp:140/90 mm hg 
PR:84 bpm 
RS: BAE+,decreased breath sounds in suprascapular area, crepitations are heard in left infraclavicular area, bilateral infraaxillary areas, bilateral infrascapular areas,interscapular area.

Cvs:S1,S2 heard, no murmurs

Fever spikes+

Rx:
Head end elevation
Fluid and Salt restriction
O2 inhalation
Tab. Nicardia Retard 20 mg/PO/TID
Tab. Lasix 40 mg/PO/BD
Inj. Augmentin 600 mg/IV/OD (D3) 
Neb with Duolin -8th hrly
          With Budecort -12th hrly
Tab. PCM 650mg/PO/TID
Tab. Pan 40 mg/PO/OD
Bp, Temp, PR SpO2 charting










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