Prefinal practical examination - 1/4/2022
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K.Keshitha
Roll no - 64
9th semester
This case is about a 75 year old female , a housewife , residing in miryalguda was brought to the hospital in unconscious state with unrecordable BP and pulse.
Time line of events:
Post CPR vitals:
Afebrile
BP 170/100
PR 110 BPM
CVS S1,S2 +
RS BAE+, Decreased air entry in rt mammary area
There were myclonic movements noted on 29th march and 30th march. They were not seen before by the attenders.
https://youtube.com/shorts/KpNRO6Ri_PI?feature=share
PERSONAL HISTORY:
*Diet - Vegetarian
* Appetite - Normal
* Bowel and Bladder - Regular
* Sleep - Adequate
* Allergy- None
* Addition- None
FAMILY HISTORY:
There is no significant family history.
GENERAL EXAMINATION :
The patient is unconscious.
Well built and nourished.
Pedal edema present - upto the knee - pitting type.
Palor is present
No- icterus, clubbing, cyanosis, lymphoedenopathy.
Vitals :
On 30 March 2022 :
*Temperature - 98 degree F
* Pulse - 90 bpm
* Respiratory rate - 18cpm
*BP - 160/90 mm of Hg
* SpO2 - 98(on ventilator) - 35 on admission.
On 31 March 2022 :
Temperature - 102F
Pulse 118 bpm
RR- 12 cpm
BP - 160/80 mmHg
Spo2 - 98(on ventilator)
GRBS - 146 mg/dl
Systematic examination:
CNS:
Corneal, conjunctival reflexes absent
Dolls eye movement is absent
Babinskis reflex is mute
Hypotonia is seen in all limbs
Areflexia seen
Myoclonic jerks occured for 2 days and stopped
CVS: JVP NORMAL, Apex beat 5th Intercostal space Mid Clavicular line s1s2 +
RS: BAE + , decreased air entry on right side IMA, IAA
P/A: soft, non tender , BS +
Provisional diagnosis:
Acute type 2 respiratory failure secondary to Obstructive Sleep Apnea and Hypertension following a Cardiac arrest.
INVESTIGATIONS :
29/03/2022 :
* Hemogram- of 29 and 30th of march
HB 8.5 to 8.6
TLC 13,600 to 15,200
PCV 27.4
MCH 26.6
MCHC 31
PLT 2.0 to 1.4
P.S NORMOCYTIC, NORMOCHROMIC with neutrophilic leucocytosis
Serum iron : 45ug/dl
RBS: 211mg/dl
HbA1c : 6.8%
*Liver Function Tests-
TB 0.57
DB 0.16
AST 148
ALT 123
ALP 180
TP 4.7
ALB 2.2
* Renal Function tests :
Blood Urea: 49mg/dl
S. Creatinine: 1.9mg/dl
Na 142
K 4.7
Cl 98
* CUE:
ALB ++
Sugars nil
Pus cells 4-5
Epithelial cells 1-2
*ABG :
ABG post CPR fio2 100%
pH 6.88
PCo2 107
PaO2 77.4
HCO3 1108
SpO2 82.5
Interpretation : Metabolic and respiratory acidosis
ABG day 0 evening fio2 80%
pH 7.46
PCo2 32.8
PaO2 146
HCO3 23.1
SpO2 96.8
ABG day 1 morning fio2 40%
pH 7.4
PCo2 31.9
PaO2 80
HCO3 21.5
SpO2 94.7
On 30/3/22
Renal function tests:
Serum creatitnine : 2.8
Uric acid: 11.8
Urea: 89
Na: 143
K: 4.2
Cl: 102
Phosphorus: 5.1
Ca: 8.7
RBS: 221
CUE:
Alb: 2+
Pus cells: 4 to 5
RBCs : 6 to 8
Chest x ray: on 29th
30/3/22
On 31/3/22
ECG:
Post CPR:
Day 1:
2D echo
Concentric LVH
Sclerotic AV
EF 58%
RVSP 35 mmHg
Diastolic dysfunction +
Treatment
Ventilatory support
IVF NS/RL @50ML/HR
Inj. Pan 40 mg IV OD
Inj. Zofer 4 mg IV SOS
Inj. Midazolem titrate B/W 0.1 - 3 mg/Kg
Inj. Atracurium @ 0.8ml/hr (10mcq/hr)
Inj. Levipil 1gm IV STAT
Inj. Levipil 500 mg IV TID
Inj. Clexane 60mg sc OD
Inj. Ceftriaxone
RT feeds milk+protein 100ml, water 100ml q4hrly
Propped up position
Air bed with position change 2nd hourly
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