A 33 year old male came to the casualty around 10 pm with
Chief complaints of sob since 3 days.
Fever since 10 days
Cough since 10 days
Chest pain since 10 days
Pain abdomen since 10 days
HOPI :
Patient was apparently asymptomatic 10 days back, then he developed fever associated with chills and body pains, headache, sore throat. Patient had cough which was productive with white coloured sputum. Then patient got tested positive for Widal after 4 days of onset of fever. He used symptomatic medication for a week. Then, he developed SOB since 3 days for which he got admitted in Nalgonda. SOB was insidious in onset, gradually progressed from grade 2 to grade 4 since past 10 days, SOB was more in sitting position and relieved on lying down, as his SOB aggravated, patient got shifted from that hospital and presented to our casualty. Patient also used to complain of intermittent chest pain, pain abdomen since 15 days
Past History :
Admitted to a hospital for pain abdomen for 4 days
Not a k/c/o HTN, DM, CAD, ASTHMA, EPILEPSY, THYROID DISEASE.
Personal history:
Constipation since 4 days
Appetite : decreased
Sleep : disturbed
Chronic alcoholic since 10 years, alcohol consumption increased since past 6 months. Consumes half bottle of whiskey daily since past 6 months. Last consumed 10 days back.
Family History : No significant family history.
On examination:
Moderately built and moderately nourished.
Vitals at the time of admission
BP - 100/80 mm Hg
SpO2 - 22 , on 15 lit of O2 - 71
RR - 66 cpm
PR - 127
Temp - 99 F, 103 F @ 10:45 pm
Systemic examination :
CVS : S1, S2 +
RS : b/l Crepitations present
P/A : soft/non-tender
CNS : NAD
PROVISIONAL DIAGNOSIS :
Community acquired pneumonia with septic shock with MODS
INVESTIGATIONS :
1. Blood Grouping and Rh typing
2. Hemogram
17-09-22 12:50 pm
17-09-22
5. RBS
6. ABG
16-09-22 (7:55 pm) At the time of admission
16-09-22 (8:09 pm) At 15 lit of O2
17/09/22; 2:15 am
17/09/22 7:20 am - CPAP mode
17-09-22 (3:30 pm) on CPAP
18-09-22
19-09-22
20-09-22, 1:49 pm
21-09-22, 3:37 pm
22-09-22, 12:27 am
7. Serum amylase
8. Serum lipase
9. Chest x-ray
17-09-22
19-09-22
10. 2D echo
17-09-22
22-09-22
11. Ultrasound scan abdomen
12. RT-PCR
13. Anti HCV Antibodies
14. Anti HbsAg
15. CUE
16. ECG
16-09-22
17 -09-22
18-09-22
19-09-22
20-09-22, 7:25 am
21-09-22; 7:30 am
17. HRCT chest
18. Culture and sensitivity report
21-09-22
20. APTT
21. PT, INR
CROSS CONSULTATION NOTES :
Treatment : Patient was initially put on noninvasive ventilation. Later as the condition did not improve, patient was intubated around 12 am. Patient was sedated by giving Atracurium and Midazolam
Intubation done due to respiratory distress
Ventilator settings :
16-09-22 - on CPAP
17-09-2023
Mode : SIMV-VC
RR : 14
FiO2 : 80
PEEP : 5 cmH2O
VT : 450 ml
Tinsp : 1.4
18-09-22 - changed to CPAP VC mode at 4:30 pm
19-09-22 - CPAP-VC
SOAP NOTES :
ICU bed 3
33yr old male Admit on 16/09/22
Day 3
S: Pt is on day 3of mechanical ventilation
FEVER SPIKES Present
O: Pt SIMV VC MODE
GCS: E1VTM1
RR TOTAL:37
RR:16
Fio2:50
PEEP:5
VT: 450
VITALS:
BP: 110/70mmhg
PR: 162bpm
RR: 39cpm
Temp: 102.6f
GRBS: 125mg/dl at 6:00am
SpO2: 93%
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS: BAE+ B/L DIFFUSE CREPTS
CNS: B/L pupils NSRL
A: COMMUNITY ACQUIRED PNEUMONIA WITH MODS
P:
Inj.Neomol 1g/iv sos if temp >101f
Tab.Dolo 650mg RT/TID
mucomist nebulisation 2 nd hrly f/by suction
Salbutamol 4th hrly
Budecort 12 th hrly
Duolin 8 th hrly
Day 4
S:
Patient is on T piece, fully conscious
O:
Vitals
Bp: 110/80
PR: 96
RR: 20
Temp: 101.4
GRBS: 111mg/dl
GCS - E4VTM6
Cvs: S1 S2 +
RS- BAE +
P/A- soft, non tender
CNS- NAD
A:
Community acquired pneumonia (sepsis with MODS)
P:
1. INJ. PIPTAZ 2.25 mg IV BD
2. INJ. HYDROCORTISONE 100 mg IV/SOS
3. INJ. NEOMOL 1 G IV IF TEMP. >102 °F
4. T. DOLO 650 MG RT/TID
5. NEBULIZATION WITH SALBUTAMOL 4TH HOURLY, BUDECORT 12TH HOURLY, DUOLIN 8TH HOURLY
6. Plan to extubate
Day 5
S:
Patient is on T piece, fully conscious
No complaints
2 fever spikes since yesterday
O:
Vitals
Bp: 130/90
PR: 102
RR: 24
Temp: 101.4
GRBS: 135 mg/dl
GCS - E4VTM6
Cvs: S1 S2 +
RS- BAE +
P/A- soft, non tender
CNS- NAD
A:
Community acquired pneumonia (sepsis with MODS)
P:
1. ORAL FLUIDS UPTO 2 LITRES
2. INJ. NEOMOL 1 G IV IF TEMP. >102 °F
3. T. DOLO 650 MG RT/TID
4. NEBULIZATION WITH SALBUTAMOL 4TH HOURLY, BUDECORT 12TH HOURLY, DUOLIN 8TH HOURLY
5. INJ. PIPTAZ 2.25 MG IV BD
Day 6
S:
Patint is on ventilation (SIMV -VC mode).
O:
Ventilator settings :
FiO2 - 70, PEEP-8, RR- 22, SpO2-94
Vitals :
Bp: 80/60 mm Hg(Ionotropic supports - Dobutamine and Noradrenaline)
PR: 46 bpm
RR: 40 cpm
Temp: 100.4 F
GRBS: 177 mg/dl
GCS - E1VTM1
Cvs: S1 S2 +
RS- BAE +
P/A- soft, non tender
CNS- NAD
A:
Community acquired pneumonia (sepsis with MODS)
P:
1. RT FEEDS (4TH HOURLY MILK, 2ND HOURLY WATER)
2. INJ. NEOMOL 1 G IV IF TEMP. >102 °F
3. T. DOLO 650 MG RT/TID
4. NEBULIZATION WITH SALBUTAMOL
5. INJ. PIPTAZ 2.25 MG IV BD
6. INJ. NORADRENALINE 2 AMPOULES IN 45 ML NS 5ML/HR
7. INJ. DOBUTAMINE 1 AMPOULE IN 45 KL NS 4 ML/HR
8. INJ. HAI 10U IN 25% D
9. INJ. 10% 10 ML CALCIUM GLUCONATE IV OVER 10 MIN (i/v/o hyperkalemia [K+: 6.0] )
10. IVF NS @50 ML/HR
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