39 YEAR OLD MALE WITH SHORTNESS OF BREATH

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 A 39 year old male came to opd with c/o shortness of breath grade 4 since 3 months.

HISTORY OF PRESENTING ILLNESS:- 

Patient was apparently asymptomatic 2 years back , 

then the patient had an episode of giddiness ?due to shock (from the death of his brother in law) ,for which he went to a local hospital and got diagnosed with hypertension.

Since then the patient was started on increasing doses of Telma and later Telma -H, but the patient was not compliant to the medication. He used to take the medication only when there's occasional neck stiffness and pain.

History of mild shortness of breath and chest pain 3 months back, not associated with cough, fatigue for which he went to a local hospital where patient was started on cilnidipine.

Since then complaints were on and off but did not subside.

Sob worsened since one month to grade 4 , associated with mild b/l pedal edema , non pitting, upto knees

H/o fever 20 days back, associated with cough and weight loss (patient's waist size reduces from 32 to 28 in the span of 1 month)

Then patient came to our hospital with grade 4 sob and got admitted.

Extended personal history:-

37 yrs old male elder son of his family who studied till 9th standard later he discontinued because of financial issues there after he started his own business at the age of 12yrs( paper recycling) runned for about 3yrs and discontinued because of loss in his business and returned to his grown up place there after for about 1-2yrs he went for farming with his parents and later because in need of more money he started working as lorry cleaner( as he do overnight work and feel tired he started getting habituated to drink alcohol and smoking)in the gap of 2 yrs he learned how to drive and he continued as lorry driver( he returns to home once in a week, used to continuously drink alcohol more than a full bottle with dec intake of food, in between a week too she used to drink).After 8yrs (2014) he got married later after this children were born he discontinued as lorry driver and started working as daily labourer where he used to lift heavy weights after doing work to overcome his tiredness he used to drink alcohol (180ml/day). one fine day (in the year of 2020) he went to his sister house(family gathering),there was an incident of sudden death of his brother in law he became very anxious( as his sister lost his husband in young age) and weak when he got his first bp check ( 190/110) he was prescribed anti htn but he refused to take it regularly( as there is a misnom in his village not to take antihtn in a very young age) and to overcome his sorrowness he started taking much more alcohol and smoking very regularly.

All his present complaints started since the month of November (2021) where he first noticed pedal edema and sob on exertion

PAST HISTORY:-

No similar complaints in the past (before 2 years) No significant medical or surgical history

Not a known case of DM, bronchial asthma, CAD, Epilepsy

FAMILY HISTORY:-

 No family history of HTN, DM, bronchial asthma, epilepsy

Addictions:-

Patient is a chronic alcoholic and chronic smoker since 15 years

Alcohol 90-150 ml per day whiskey/brandy 

1-2 beedi per day for 15 years

General examination:- 

Patient is conscious,coherent , cooperative, 

Oriented to time , place and person

Pallor present

No signs of icterus, lymphadenopathy.

Mild Pedal edema present in both legs

Temp:- 98.3 F

BP:- 190/120 mmhg

RR:- 20 cpm

PR:- 85 bpm

Systemic examination:-

CVS- S1,S2 heard, no murmurs

Respiratory system:- BAE+

Decreased breath sounds in Right ICA, MA, IAA, ISA.

P/A :- soft, non tender, distended and umbilicus everted

CNS - NAD

Investigations:-

Fever chart:

Chest X-ray: (24/7/23)

Right sided Hydropneumothorax

Culture report: 

Specimen-sputum

DIAGNOSIS:

1. CKD on MHD 

2. Right sided Haemothorax

3. Anemia of chronic disease

4. Conjugated Hyperbilirubinemia 

5. High SAAG, Hugh protein ascites secondary to CHF

6. Heparin Induced Thrombocytopenia 

7. ICD INSITU (DONE ON 15/7/23)

8. K/C/O Hypertension Since 3 Years

Last dialysis done on 22/7/23

Treatment:-

1. Fluid restriction < 1 L/day

2. Salt restriction < 2g/ day

3.INJ ERYTHROPOIETIN 4000 IU S/C weekly once

4. Tab METALAZONE 10mg PO/BD

5. TAB ARKAMINE 0.1mg PO TID

6.Tab NICARDIA 20mg PO/TID

7.Tab DYTOR 40mg PO/BD

8.Tab MET-XL 50 mg PO/BD

9.Tab SHELCAL CT 500mg PO/OD

Further plan: Hemodialysis with PRBC transfusion.

SOAP NOTES:

24/07/2023

ICU bed 1

S: 

Patient mentions decreased appetite. Whenever he attempts to eat, he’s experiencing shortness of breath. 

Sleep is disturbed owing to difficulty in breathing. 

Pain around ICD site +

Patient has not passed stools in two days. 

No fever spikes.

O: 

Pt is conscious, coherent, cooperative. Oriented to time,  place and person.

BP - 140/80 mmHg

PR- 145 bpm 

RR- 26 cpm 

Temp - 98.6 F                   

SpO2 - 93 %on 6 lt O2

CVS - S1 S2 heard, no murmurs 

RS - BAE+

Decreased breath sounds in Right ICA, MA, IAA, ISA.

P/A - soft and non tender,distended and umbilicus everted

CNS - no FND

A: 

1. CKD on MHD 

2. Right sided Haemothorax

3. Anemia of chronic disease

4. Conjugated Hyperbilirubinemia 

5. High SAAG, Hugh protein ascites secondary to CHF

6. Heparin Induced Thrombocytopenia 

7. ICD INSITU (DONE ON 15/7/23)

8. K/C/O Hypertension Since 3 Years

Last dialysis done on 22/7/23

P:

1. Fluid restriction < 1 L/day

2. Salt restriction < 2g/ day

3.INJ ERYTHROPOIETIN 4000 IU S/C weekly once

4. Tab METALAZONE 10mg PO/BD

5. TAB ARKAMINE 0.1mg PO TID

6.Tab NICARDIA 20mg PO/TID

7.Tab DYTOR 40mg PO/BD

8.Tab MET-XL 50 mg PO/BD

9.Tab SHELCAL CT 500mg PO/OD

Further plan: Hemodialysis with PRBC transfusion.

25/07/2023

ICU bed 1

S: 

Patient mentions decreased appetite. Whenever he attempts to eat, he’s experiencing shortness of breath. 

Sleep is disturbed owing to difficulty in breathing. 

Pain around ICD site +

Patient has not passed stools in two days. 

No fever spikes.

O: 

Pt is conscious, coherent, cooperative. Oriented to time,  place and person.

BP - 130/80 mmHg

PR- 123bpm 

RR- 22cpm 

Temp - 98.6 F                   

SpO2 - 95%on 6 lt O2

CVS - S1 S2 heard, no murmurs 

RS - BAE+

Decreased breath sounds in Right ICA, MA, IAA, ISA.

P/A - soft and non tender,distended and umbilicus everted

CNS - no FND

A: 

1. CKD on MHD 

2. Right sided Haemothorax

3. Anemia of chronic disease

4. Conjugated Hyperbilirubinemia 

5. High SAAG, Hugh protein ascites secondary to CHF

6. Heparin Induced Thrombocytopenia 

7. ICD INSITU (DONE ON 15/7/23)

8. K/C/O Hypertension Since 3 Years

Last dialysis done on 22/7/23

P:

1. Fluid restriction < 1 L/day

2. Salt restriction < 2g/ day

3.INJ ERYTHROPOIETIN 4000 IU S/C weekly once

4. Tab METALAZONE 10mg PO/BD

5. TAB ARKAMINE 0.1mg PO TID

6.Tab NICARDIA 20mg PO/TID

7.Tab DYTOR 40mg PO/BD

8.Tab MET-XL 50 mg PO/BD

9.Tab SHELCAL CT 500mg PO/OD

Further plan: Hemodialysis with PRBC transfusion.

Patient shifted to AMC

26.07.2023

AMC bed 2

S: 

C/O SOB decreased since yesterday

No Fever spikes 

Patient is feeling symptomatically better than yesterday 

O: 

Pt is conscious, coherent, cooperative. Oriented to time,  place and person

BP - 120/70 mmHg

PR- 128 bpm (irregularly irregular)

RR- 28 cpm 

Temp - 99 F

SpO2 - 87 % on RA,96% on 4 lt O2

CVS - S1 S2 heard 

RS - BAE+,crepts present in b/l IAA

Decrease breath sounds in right IAA, IMA

P/A - soft and non tender,distended and umbilicus everted

CNS - no FND

Lab-

Platelet count is in increasing trends

A: 

1. CKD on MHD 

2. RIGHT SIDED HYDROPNEUMOTHORAX 

3. ATRIAL FIBRILATION 

4.ANEMIA OF CHRONIC DISEASE 

5.CONJUGATED HYPERBILIRUBINEMIA

6.HIGH SAAG HIGH PROTEIN ASCITIES 

SECONDARY TO CHF

7.THROMBICYTOPENIA ( Resolved)

8.ICD INSITU (Reinserted on 24/7/23)

9.K/c/O HYPERTENSION since 3 Years

P:

1. Fluid restriction < 1.5 L/day

2. Salt restriction < 2g/ day

3.INJ ERYTHROPOIETIN 4000 IU S/C weekly once

4.INJ IRON SUCROSE 100mg IV weekly once

5.INJ CLINDAMYCIN 600 IV TID

6.TAB METALOZONE 10 mg PO/BD

7.TAB NICARDIA 20mg PO/TID

8.TAB ARKAMINE 0.1 mg PO/TID

9.Tab MET-XL 50 mg PO/BD

10.Tab SHELCAL - CT 500mg PO/OD

11.Tab NODOSIS 500 mg PO/BD 

Plan-

Hemodialysis with PRBC transfusion tomorrow 

To start on Tab Amiodarone for Atrial fibrillation

Hemogram (27/7/23)

ECG (28/7/23)

Patient had an episode of monomorphic VT and was given inj.met xl 5mg iv/stat followed by inj.diltiazem 5mg iv/stat at around 10:50 am

ECG (29/7/23)

Patient had a seziure episode followed by AF with ?rbbb 

Followed by sudden cardiac arrest. cpr was initiated meanwhile intubation was done and rosc acheived for 10 min and again arrested and declared death at 8:30.