39 year old male patient presents to casualty with complaints of shortness of breath

A 39 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:



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


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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