88 yrs old Female came to casualty with......


February 22,2023
A  88 yrs old  Female  presented to casualty with
C/o  irrelevant talk and altered mental status since 10 days
Shortness of Breath since 3 days 
Cough since 3 days  

HISTORY OF PRESENT ILLNESS:
Patient was  asymptomatic 10 days ago and then developed altered mental status on & off and her speech being non cohorent  at times and later becoming normal by herself , each episode  lasting for 10- 15 mins .
Productive cough 2 days ago 
Now dry cough
Shortness of breath since  3 days  initially grade III
progressed  grade IV in these  3 days. 
Later went to outside hospital and 2 D echo was done  
2 D echo ( CAD , LAD + territor) , Global Hypokinesia , Severe LV dysfunction 
No history of chest pain , palpitations , giddiness. 
On 20/02/23 presented to causality with complaints of loss of appetite since one day and not talking to anyone since morning as informed by attender . So they took her to hospital and s.electrolytes was done with s. Potassium of 2meq. They gave her syp. Potklor and s.k+ was 5.8 when presented to us

HISTORY OF PAST ILLNESS:

N/ K/C/O HTN , DM , CVA , Epilepsy , Asthma 

PERSONAL HISTORY: 
DIET: MIXED 
APPETITE: DECREASED 
BOWEL AND BLADDER MOVEMENTS: REGULAR 
SLEEP: ADEQUATE 
ADDICTIONS: NO

ON EXAMINATION :

PATIENT IS CONSCIOUS NON COHERENT AND COOPERATIVE 

GENERAL EXAMINATION:
NO PALLOR ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY EDEMA 


VITALS:
BP- 90/50 MMHG
PR- 85BPM
RR- 24CPM
SPO2- 88% @RA , 94% on HIGH FLOW O2
GRBS- 126MG/DL

CVS- S1 S2 HEARD. NO MURMURS 

RS -Barrel shaped chest , BAE + 
        Crepts + , Left IAA ,ISA
       Bronchial  breath sounds , 
        Right ISA 
       
  


PA - soft , nontender
TEMP - AFEBRILE 
CNS : Not oriented to T /P/P
           NFD

Urinary Electrolytes:
Chloride - 94
Potassium - 30
Sodium - 127

GAIT - NORMAL 
GCS- E4V5M6



PROVISIONAL DIAGNOSIS:
HEART FAILURE WITH REDUCED EJECTION FRACTION SECONDARY TO CAD ?
WITH ANT. WALL MI ?
WITH TRUE HYPONATREMIA 
AND WITH RIGHT MILD PLEURAL EFFUSION ?

INVESTIGATIONS:
ON 3/04/2023
ECG :


Arterial blood gas :

Chest X -RAY :


Blood UREA :


SERUM ELECTROLYTEs :



TROP I :



HEMOGRAM:




CHEST X RAY  LATERAL VIEW :






2D ECHO REPORT 



Youtube link for 2d echo 
https://youtu.be/P_Gloc5y3Rk
Rx :

1. INJ. LASIX 20 mg /IV /BD
  
2. T . ECOSPRIN GOLD PO/ H/S
       75/75/10 mg 

3. T. MET XL 25 mg PO /OD

4.  INJ. NORAD - DS ( 2 ampoules  in 46 ml NS /IV 
                                           @ 6 ml / hr )
5. SYP . POTKLOR 15 ml  in 1 glass of water PO / TID

6. Fluid restriction

7. O2 supplementation to maintain
        Sp O 2 > 94%
 
ON 4/02/23

 Patient is oriented to time and place 
  
VITALS

Bp:- 80/40 mmhg 
Pr :- 78 bpm
RR : 22 cycles / min
SpO2: 88% @RA , 94% on HIGH FLOW O2

Rx:

1. T . ECOSPRIN GOLD PO/ H/S
       75/75/10 mg 

2. T. MET XL 25 mg PO /OD

3. INJ. NORAD - DS ( 2 ampoules  in 46 ml NS /IV 
                                           @ 6 ml / hr )
4. SYP . POTKLOR 15 ml  in 1 glass of water PO / TID

5. Fluid restriction

6. T. SPIRINOLACTONE 50 mg /PO/OD

7. O2 supplementation to maintain
        Sp O 2 > 92%
8. Nebulization with SALBUTAMOL 1 respule /stat /
9. Inj. HEPARIN 4000IU/IV/BD





  







21/02/2023

Icu



S:

No fresh complaints 


O:

O/E: pt is irritable 

Temp- 98.6F

Bp-100/70mmHg

Pr- 80bpm

Rr-16cpm

Spo2-98% on 2l oxygen 


Systemic Examination:

Cardiovascular System : S1, S2 heard, no

murmurs


Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.


Central Nervous System : patient is irritable

E3v2m5


Per abdomen : soft, non tender. No organomegaly


A:


ALTERED SENSORIUM secondary to ?UREMIC ENCEPHALOPATHY

WITH HEART  FAILURE With REDUCED EJECTION FRACTION  SECONDARY TO

TO CORONARY ARTERY DISEASE WITH ANTERIOR WALL MI WITH HYPERKALEMIA SECONDARY TO INCREASED POTASSIUM

WITH ILD WITH R. LOWER-LOBE CONSOLIDATION 


 P:


  1. 200ml milk 4th hourly 
  2. 100ml water 2nd hourly 
  3. T. Carvidolol 3.125 mg/Rt/OD
  4. T.ecospirin gold 75/75/10 mg RT/hs
  5. Fluid restriction <2l per day
  6. O2 inhalation to maintain spo2>94 and intermittent cpap
  7. Pr rr bp monitoring hourly
  8. Inj.25 dextrose with 6u insulin stat iv


22/02/2023


S:

No fresh complaints 


O:

O/E: pt is irritable 

Temp- 98.6F

Bp-100/70mmHg

Pr- 80bpm

Rr-16cpm

Spo2-98% on 2l oxygen 


Systemic Examination:

Cardiovascular System : S1, S2 heard, no

murmurs


Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.


Central Nervous System : patient is irritable

E3v2m5


Per abdomen : soft, non tender. No organomegaly


A:


ALTERED SENSORIUM secondary to ?UREMIC ENCEPHALOPATHY

WITH HEART  FAILURE With REDUCED EJECTION FRACTION  SECONDARY TO

TO CORONARY ARTERY DISEASE WITH ANTERIOR WALL MI WITH HYPERKALEMIA SECONDARY TO INCREASED POTASSIUM

WITH ILD WITH R. LOWER-LOBE CONSOLIDATION  with URETHRAL CARUNCLE


 P:


  1. 200ml milk 4th hourly 
  2. 100ml water 2nd hourly 
  3. T. Carvidolol 3.125 mg/Rt/OD
  4. Inj. LASIX 40mg BD/IV/
  5. T. ECOSPIRIN 75/75/10 mg rt od
  6. Fluid restriction <2 lit per day
  7. Neb with MUKAOMIST QID
  8. Neb with IPRAVENT TID
  9. T.NODOSIS 500mg iv bd
  10. O2 inhalation to maintain spo2 >94 with intermittent cpap
  11. Monitor vitals

23/02/2023


S:

Stools: not passed

Fever: no fever spikes


O:

O/E: pt is conscious non coherent 

Temp- 98.6F

Bp-130/70mmHg

Pr- 96bpm

Rr-16cpm

Spo2-98% on 1l oxygen 


Systemic Examination:

Cardiovascular System : S1, S2 heard, no

murmurs


Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.


Central Nervous System : patient is irritable

E3v2m5


Per abdomen : soft, non tender. No organomegaly


A:


ALTERED SENSORIUM secondary to ?UREMIC ENCEPHALOPATHY

WITH HEART  FAILURE With REDUCED EJECTION FRACTION  SECONDARY TO

TO CORONARY ARTERY DISEASE WITH ANTERIOR WALL MI WITH HYPERKALEMIA SECONDARY TO INCREASED POTASSIUM

WITH ILD WITH R. LOWER-LOBE CONSOLIDATION  with URETHRAL CARUNCLE


 P:


  1. 200ml milk 4th hourly 
  2. 100ml water 2nd hourly 
  3. T. Carvidolol 3.125 mg/Rt/OD
  4. Inj. LASIX 40mg BD/IV/
  5. T. ECOSPIRIN 75/75/10 mg rt od
  6. Fluid restriction <2 lit per day
  7. Neb with MUKAOMIST QID
  8. Neb with IPRAVENT TID
  9. T.NODOSIS 500mg iv bd
  10. O2 inhalation to maintain spo2 >94 with intermittent cpap
  11. Inj norad ns 2 ampules in 46ml ns @13ml/hr
  12. Inj dobutamine 250 mg in 50ml ns @ 3ml/hr
  13. Monitor vitals 2 hourly


25/02/2023

Icu

Unit1


S:

Stools not passed 

Fever spike 101 f @ 2am



O:

O/E: conscious coherent and oriented to place 

Temp- 98f

Bp-80/40 mmhg on NORAD 12 ml/hr and DOBUT 9ml/hr

Pr- 106 bpm

Rr-20cpm

Spo2-96 % on 2l oxygen 

Grbs: 97mg/dl


Systemic Examination:


Cardiovascular System : S1, S2 heard, palpable p2 +


Respiratory System : decreased air entry on rt side 

AA Crepts positive on left side


Central Nervous System : patient is oriented to place

E4v5m6


Per abdomen : soft, 4/min


A:


ALTERED SENSORIUM secondary to ?UREMIC ENCEPHALOPATHY

HYPOXIC ENCEPHALOPATHY WITH HEART FAILURE WITH MIDRANGE EJECTION FRACTION(EF 42%)

 SECONDARY TO ANTERIOR WALL MI

WITH HYPERKALEMIA SECONDARY TO INCREASED INTAKE OR KIDNEY INJURY 

WITH ILD WITH L. LOWER-LOBE CONSOLIDATION  with URETHRAL CARUNCLE

WITH G1 BED SORE


 P:


  1. 200ml milk 4th hourly 
  2. 100ml water 4 th hourly 
  3. Inj. NORAD 14mg in 46 ml ns @1 ml/hr ( increase or decrease to maintain MAP OF 55 mmhg
  4. Inj DOBUTAMINE 250mg in 50ml NS @ 8 ml/hr
  5. T. Carvidolol 3.125 mg/Rt/OD
  6. INJ. Ceftriaxone 1gm/iv/bd
  7. Inj. LASIX 40mg BD/IV/BD(if sbp> 110 without narad support 
  8. T. ECOSPIRIN 75/75/10 mg rt OD
  9. Neb with IPRAVENT TID
  10. T.NODOSIS 500mg iv bd
  11. O2 inhalation to maintain spo2 >94 
  12. Monitor vitals

26/02/2023

Icu

Unit1


S:

Stools passed 

No fever spikes



O:

O/E: conscious coherent and oriented to place 

Temp- afebrile

Bp-70/50 mmhg on NORAD 8ml/hr and DOBUT 5ml/hr

Pr- 92bpm

Rr-20cpm

Spo2-96 % on RA

Grbs: 118mg/dl


Systemic Examination:


Cardiovascular System : S1, S2 heard, NO MURMURS 


Respiratory System : decreased air entry on rt side 

AA Crepts positive on left side


Central Nervous System : patient is oriented to place

E4v5m6


Per abdomen : soft, 4/min


A:


ALTERED SENSORIUM secondary to ?UREMIC ENCEPHALOPATHY

WITH HEART FAILURE WITH MIDRANGE EJECTION FRACTION(EF 42%)

 SECONDARY TO ANTERIOR WALL MI

WITH HYPERKALEMIA SECONDARY TO INCREASED INTAKE OR KIDNEY INJURY 

WITH PRE-RENAL AKI

WITH ILD WITH R L. LOWER-LOBE CONSOLIDATION  with URETHRAL CARUNCLE

WITH G1 BED SORE


 P:


  1. Inj. NORAD DS 14mg in 46 ml ns @10 ml/hr ( increase or decrease to maintain MAP OF 55 mmhg
  2. Inj DOBUTAMINE 250mg in 500ml NS @ 8 ml/hr increase or decrease to maintain a MAP of 55 mmhg
  3. T. Carvidolol 3.125 mg/ PO BD
  4. INJ. Ceftriaxone 1gm/iv/bd (day4)
  5. Inj. LASIX 40mg BD/IV IF SBP > 110 mmmhg without NORAD support 
  6. T. ECOSPIRIN 75/75/10 mg OD PO
  7. Neb with IPRAVENT TID
  8. T.NODOSIS 500mg PO BD

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