A 42yr old Male with Bilateral Lower lobe consolidation , Necrotising Pneumonia with Pneumothorax, DM- since 4 yrs , Severe Hypovolemia? ACUTE Anterior wall MI? Myocardial depression 2° to Lactic Acidosis? Septic shock / ? Cardiogenic Shock

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 42Y male Patient came to the opd with chief complaints of:

Shortness of breath since 15d

Cough with expectorant since 15d

History of Presenting Illness:

Pt was apparently asymptomatic 15days back

He then developed right sided lower chest pain since 15d

Breathlessness which was insidious in onset Grade I-II , Not associated with orthopnea, PND 

No wheeze

Cough with expectoration red in color progressive in nature, non foul smelling

Fever - Low grade , intermittent associated with chills

Loss of weight, loss of appetite

The patient was then admitted to outside Hospital at Hyderabad

The outside HRCT - CHEST showed Right lower lobe dense pneumonia

USG ABDOMEN showed Grade II  RPD changes

And he was admitted with diagnosis of Pneumonia with severe hyponatremia, ? SIADH , dyselectrolemia and was Started on 

IV antibiotics, PPI, MVI, Antipyretics, Anti histamines, Anti tussives ,IV fluids, pottasium and sodium correction, Nebulization, Kidney protectives, HAI acc to GRBS and other supportive management

Investigations -

Hemogram showed Leucocytosis ( 52,200) 

Creatinine levels elevated

LFT showed hypoalbunemia ( 2.9) 

CUE showed Albumin +1, Pus cells ( 6-8)

2D echo showed Normal LV function with EF - 64%

The Pt had persistent pain in abdomen . 

Endoscopy was done showing Antral atrophic mucosa

During hospitalization CBP,urea, creatinine electrolytes were monitored daily

Repeated urea and creatinine levels were decreasing in trend

Repeated electrolytes were improving in trend

Pt was stabilized well and discharged with Oral antibiotics and Inj Human Mixtard

Even after the discharge the patient had persistent cough and shortness of breath and came to the pulmonology OPD and was admitted there on 20/11/2021

Past History:

Known case of diabetic since 4 years. 

Not a Known case of Hypertension, Asthma, CAD , Tuberculosis

Course in our hospital:

He was admitted under Pulmonology department on 20/11/2021 diagnosed with Right Lower lobe consolidation ?necrotising Pneumonia with AKI and DM and he was put on IV antibiotics ( Linezolid) and supportive management

On 23/11/21 they made a diagnosis of Right lowerlobe necrotising Pneumonia with ? Pneumothorax with DM

24/11- Needle thoracocentesis was done at around 8 am. 

There was a call from Pulmonology dept in view of sudden onset of shortness of breath, tachycardia, profuse Sweating at around 2 pm

On examination:

Pt was conscious

 On NIV- CPAP VENTILATION

Bp- 70/40mm Hg

PR- 160bpm

Cvs - S1, S2 +

RS - BAE+ right side ICA,IMA,IAA coarse crepts present and Left side IAA crepts +

    Wheeze +

ECG showed HR-160bpm

    Regular rhythm

    Abnormal morphological P waves 

    ? MAT

ABG showed 

   pH - 7.24

   pCO2 - 23.8

   pO2 69.8

   St HCO3 - 11.8

   C HCO3 -9.9

2D echo showed 

    LAD territory Akinetic , Inf Wall hypokinesis

    IVC - 0.8mm N size, Collapsing

    Moderate LV dysfunction 

    EF - 40%

ABG on 25/11/21:

ABG on 26/11/21:

ABG on 26/11/21, 5pm:

Clinical images :

Radiological investigations:

Ecg at the time of admission:

Ecg at 2PM on 24/11/21:

Ecg at 3.30PM on 24/11/21:

Ecg on 25/11/21:

X ray before thoracocentesis:

X ray after Thoracocentesis:

X ray after shifting him to ICU:

X ray on 25/11/21:

X ray on 26/11/21:

X ray on 26/11/21 5pm:

Usg performed on 22/11/21:

ECG showed HR-160bpm

    Regular rhythm

    Abnormal morphological P waves 

    ? MAT

ABG showed 

   pH - 7.24

   pCO2 - 23.8

   pO2 69.8

   St HCO3 - 11.8

   C HCO3 -9.9

2D echo showed 

    LAD territory Akinetic , Inf Wall hypokinesis

    IVC - 0.8mm N size, Collapsing

    Moderate LV dysfunction 

    EF - 40%

Laboratory Investigations:

  Hb - 6.6

  TLC - 9200

  Platelet count - 1.2L

  Trop I - Negative

  Urea - 49

  Creat - 1.8

  Uric acid - 6.6

  Ca - 8.2

  Phosphate - 5

  Na - 130

  K - 3.5

  CL - 87

  Mg 1.8

  Urine for ketone bodies  - Negative

On 26/11/21:

Treatment given :

   IVF  4 unit bolus given

   Inj DILTIAZEM 12.5 mg given stat

        25mg given slow IV given

   Inj NORAD -DS 2 AMP in 50 ml NS @14ML/HR

   Inj MGSO4 , 1gm IV STAT in 100ml NS

   CARDIAC Loading dose given

Provisional Diagnosis -

 Bilateral Lower lobe consolidation , Necrotising Pneumonia with Pneumothorax

S/P Needle thoracocentesis (24/12/21)

DM- 4 yrs , Severe Hypovolemia

? ACUTE  Anterior wall MI

? Myocardial depression 2° to Lactic Acidosis

? Septic shock / ? Cardiogenic Shock

Treatment:

   IVF NS RL @ 150 ml /hr

   Inj CLINDAMYCIN 600 mg IV TID

   Inj LINEZOLOD 600 MG IV BD

   T.AZEE 500 MG RT OD

   T.PCM 650 MG RT TID

   T.TOLVAPTAN 15 MG PO BD

   Inj NOR AD - DS @14ML/HR

   NEB IPRAVENT 6TH HRLY

           Budecort 8th hrly

   NIV - CPAP VENTILATION

   Inj PANTOP 40MG IV OD

   RYLES TUBE INSERTION

   Inj NAHCO3 100 mEq IV TID IN 100ml NS

   Inj OPTINEURON 1 AMP in 100 ml NS IV OD

   Inj MGSO4 1 gm in 100 ml NS IV OD

   ABG 6th hrly

   GRBS 6TH HRLY MONITORING

   Inj H ACTRAPID SC acc to GRBS 

   2 egg whites / day

   Protein Powder 2 scoops in 100 ml milk BD

   STRICT IO CHARTING, SPO2 monitoring

   Hourly BP,PR monitoring

   Temp CHARTING 4th hrly

Soap notes 26/11/21:

S-sob decreased compared to yesterday

 fever spikes+

chest pain predominantly on the right on sitting upright.

did notnpass stools since 3 days

O-c/c/c

afebrile

tachypnoeic. with RR-46/min

BP-90/60 mmhg without ionotropes

PR-156/min

CVS:s1,s2+

R.S:bae+ end exp wheeze in all lung fielss

P/A:soft nt,bs+

i/o:3300/1500

ventilator : continous cpap-pc

peep:2

fio2:60% with pa02 109 at 6pm,Spo2:97%

grbs :8am-244-8hai

2pm-222-6hai

8pm-319-12hai

2am-199

8am-226mg/dl---8hai given.

one episode of svt with hr around 150 after tapering off ionotropes ,met xl 25mg given.

acidosis is resolving

A-b/l lowerlobe consolidation sec to necrotizing pneumonia? mrsa

with pneumothorax s/p needle  thoracocentesis on 24/ 11

with dm2 

shock  due to sepsis resolved 

CAD 

aki (pre renal due to sepsis-resolving)

siadh secondary to pneumonia -resolved.

P-ivf-ns,rl @100ml/hr

   inj linezolid 600mg /rt/bd *8

   inj clindamycin 600mg iv tid*2

   inj ceftriaxone 100mg/iv/bd *2

   tab azithromycin 500mv/po/bd *2

   neb with ipravent and budecort

   continuous cpap with intermittent chest physiotherapy.

   grbs monitoring and inj hai s/c tid

   inj hydrocort 100mg/iv/sos.

   tab met xl 12.5 mg/bd

   dre for hard stools.