3. Chief complaints: HOPI
- Fever * 3 days
- Dry cough * 3 days
- Breathlessness since yesterday night.
Patient was apparently normal three days back & she developed fever which is low
grade, continuous type associated with cough which is dry not continuous not blood
stained and not associated with chills/rigor. After that She developed
breathlessness[MMRC III] since the night before ER Presentation, which was
progressive in nature and worsened since today morning. No relieving factor. H/o
generalized tiredness (+). H/o decrease urine output (~ 100 -200 ml)since yesterday
night.
HOPI:
4. Negative history:
• No h/o vomiting ,loose stools, chest pain, burning
micturation,hematuria abdominal pain, giddiness, altered sensorium.
• No recent travel history.
• TB contact/loss of weight/loss of appetite/bleed/rashes/ joint
pain/swelling
Adayar clinic – initially presented to adayar kmh treated with
inj.hydrocortisone, nebulisers, IV fluids 1.5 litres and NIV support and
shifted with inotropes support
5. PAST HISTORY:
• RA FACTOR positive - 1 MONTH back. PATIENT started ON
T.ETORICOXIB & T.PREDINISOLONE DAILY.
• Routine neg.
6. GENERAL EXAMINATION:
• CONSCIOUS,ORIENTED. GCS – 15/15.
• FEBRILE – 101.2 F
• TACHYPNEIC
• NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA
• VITALS: BP -100/80 MMHG with 3ml/hr noradrenaline support .(taken on right
arm sitting position)
• PR- 124/MIN
SPO2 – 85 -92 @ 15 L 02
RR – 31/MIN
7. Systemic examination: Respiratory system
• Inspection: Trachea is in midline, Chest is symmetrical, no chest wall
deformity,movement of chest is equal in both sides &
normal,Abdominal thoraco breathing,Tachypneic,using accessory
muscles for respiration. No dilated or engorged veins, No
scars,swelling & visible pulsation seen.
• Palpation: Not done.
• Auscultation: bilateral extensive crepitation in all areas of chest.
• Percussion: Dull in all areas of chest..
8. SUMMARY:
• 42 YR/F CAME WITH C/O FEVER(D3), BREATHLESSNESS AT REST , DECREASE URINE
OUTPUT, GENERALISED TIREDNESS. WHILE RECEIVING PATIENT WAS FEBRILE &
TACHYPENIC , WHEEZE + .
• PATIENT WAS INTIALLY EVALUATED AT KMH ADAYAR . STARTED ON
NIV.WORSENING SHORTNESS OF BREATH AND DIFFICULTY IN LYING DOWN FLAT.
PATIENT WAS COUNSELLED FOR ICU ADMISSION AND SHIFTED TO KAMAKSHI ER
FOR FURTHER MANAGEMENT.
• INITIALLY STARTED WITH NEBULISERS 2 CYCLES, IV PARACETAMOL 1GM IV,
INJ.HYDROCORT 100 MG IV, IV FLUIDS 1000ML IV BOLUS F/B 200ML/HR.
• NIL URINE OUTPUT .
• BP WAS NOT MAINTAINED.STARTED INJ.NORADRENALINE 8ML/HR.
• PATIENT DEVELOPED B/L CREPTS+.
9. Investigations:
• ABG: PaO2/FIO2 RATIO < 100
• ECG –
• XRAY – B/L UPPER & MIDDLE ZONE INFILTRATES +. F/S/O SEVERE
ARDS.
• ECHO – LVEF 65% ,NO RWMA, NORMAL LV, IVC – COLLAPSING.
16. ICU CARE:
• PATIENT REVIEWED BY ICU TEAM IN VIEW OF Refractory HYPOXIA(84-87%) - PRONE
VENTILATION.
• Repeat ABG - ?? RESPIRATORY ACIDOSIS WITH HIGH LACTATE.
• A LINE secured at right radial
• I/V/O PERSISTENT HYPOTENSION INJ.NORADRENALINE uptitrated AND VASOPRESSIN
SUPPORT STARTED.
• BLOOD REPORTS REVIEWED leukocytosis
• Antibiotic :INJ.MEROPENAM 1GM TDS , INJ.TEICOPLANIN 400MG BD, T.AZITHROMYCIN
5OOMG 1-O-O , T.OSELTAMAVIR 75 MG 1-0-1 .
• INJ.HYDROCORTISONE 50MG 1-0-1
• INJ.CLEXANE 60MG S/C O for prophylaxis.
17. DAY 2:
• I/V/O PERSISTANT HYPOTENSION AND LACTIC ACIDOSIS . PATIENT
ATTENDERS WAS EXPLAINED IN DETAIL ABOUT ECMO TO IMPROVE
OXYGENATION.
• CTVS OPINION OBTAINED PATIENT WAS UNPRONED AFTER 16HRS
OF PRONE VENTILATION AND VenoVenous ECMO WAS PLACED
UNDER ASPETIC PRECAUTION.
• VCV MODE FIO2 : 100% SERIAL ABG WAS MONITORED
WORSENING ACIDOIS AND LACTATE LEVELS.
• PATIENT ON MAXED OUT INOTROPES LEVELS.
18.
19. DAY 2:
• PATIENT WAS ANURIC WITH SERIAL INCREASE IN LACTATE LEVELS.
CONTINUOUS RENAL REPLACEMENT DIALYSATE 800ML/POST 600ML)
THERAPY WAS INITIATED.( AT EFFLUENT RATE OF 1800 ML, PRE
400ML
20.
21. • DAY 3 PATIENT ON MAX INOTROPES SUPPORT UNDER SEDATION &
PARALYSIS SHE WAS HYPOTENSIVE,BRADYCARDIA AND HYPOXIA.
• DESPITE ALL RESUSCIATIVE MEASURE WITH ALL SUPPORTIVE
MEDICATION.
• PATIENT DETORIATES AND DECLARED DEAD.
