A 20 YEAR OLD FEMALE WITH HEART FAILURE

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GOLI HARSHITHA

Roll no : 38

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. 

20/9/21

CASE

A 20year old female came to the OPD with chief complaints of fever, vomitings and shortness of breath  since 3 days.

HISTORY OF PRESENTING ILLNESS

• Patient was apparently asymptomatic 3 days ago when she developed high grade fever(103•) associated with chills no diurnal variation , gets relieved on taking paracetamol .
• Patient also complains of  shortness of breath Grade IV(on rest).
• Patient also had vomitings 4-5 episodes per day since 3 days which is non projectile,non bilious ,non blood tinged, yellow in colour and contains food particles.
• Patient has generalised weakness since 3 days and non productive cough.

PAST HISTORY

• H/o  nephrostomy 1 year back due to urinary incontinence 
• H/o  genitourinary TB and Thimble bladder.
• H/o  ureterosigmoidostomy.
• Not a K/C/O DM, CVA, CAD, Epilepsy, Asthma.

PERSONAL HISTORY :

• Diet: mixed
• Appetite : decreased 
• Bowel and bladder movements : Regular
• Sleep: normal
• Addictions : None

FAMILY HISTORY : 

No significant Family history

GENERAL EXAMINATION :

The patient was conscious, coherent and cooperative.

The patient is a thin built and malnourished woman.

The patient has pallor.

No Lymphadenopathy, clubbing, icterus and cyanosis.

VITALS : 

Temperature - 101•

Pulse - 120 bpm

BP - 100/70 on supine position

         90/70 on standing position 

 Respiratory rate - 35cpm

SYSTEMIC EXAMINATION 

Respiratory examination- 

On inspection, the patient was tachypneic.

On auscultation, inspiratory crepitations heard in bilateral IAA and ISA.

SpO2- 93% on room air

CNS EXAMINATION 

HMF intact 

Power     Right     Left

UL           3/5         3/5

LL            3/5         3/5

Reflexes

B              2+            2+

T              2+            2+

S               2+            2+

K               2+            2+

A                +              +

Plantars : Flexion

Couldn’t elicit her power properly as she wasn’t allowing us to examine her.

CVS - S1, S2 +

Per Abdomen - soft

Non tender

Bowel sounds heard.

INVESTIGATIONS

LIVER FUNCTION TESTS

Total bilirubin: 1.76 mg/dl ( Increased)

            AST   :  247 IU/L   (Increased)

            ALT   :  272  IU/L  ( Increased)

Alkaline phosphate: 613 IU/L ( Increased)

Total proteins : 5.9 gm/dl ( Decreased)

SERUM ELECTROLYTES

Serum potassium: 3.1 mEq/L ( Decreased)

BLOOD UREA

Blood urea : 57 mg/dl ( Increased )

HEAMOGRAM

Heamoglobin : 10.1 gm/dl ( Decreased)

Total count: 2400 cells/cumm ( Decreased)

PCV : 30.1 vol% ( Decreased)

ECG

2D ECHO

ABG

At 3.00pm Pt.became tachypnoic with BP-100/60mm Hg,

RR- 32/min

PR- 142/min

Temp : 101°F

Spo2 : 84% on RA

RS : BAE (+) with B/L coarse crepts in ISA 

Pt was drowsy but arousable

ABG showed (severe metabolic acidosis )

pH - 7.054 

pCo2 - 9.7 

pO2 - 93.4

Spo2- 93.1

HCo3(stat) - 6.2

HCo3 (c) - 2.6

Maintain Sp02 >90% by oxygen supplemention

INJ .LASIX 20mg/IV/ stat

INJ NEOMOL 1mg/ IV /stat

Pt landed in  Acute heart failure secondary to myocardial depression.

We shifted her to icu and gave treatment.

After giving Lasix ,crepts disappeared and chest was clear on auscultation .

Her vitals were stable and spo2- was 98% with 4 lit oxygen.

We got ecg done which was showing st depressions in inferior and v3-v6 leads.

Echo was done and there was no RWMA.

Intubation notes 

 

At 4 : 30 pm ,pt became unresponsive with PR - 186/min (ECG showing SVT with rate related ST Depression 

With BP - 100/60 mm hg 

Spo2 - 96% on RA 

In v/o SVT INJ.DILTIAZEM 12.5 mg/IV /STAT 

Inj.NaHCO3 100mEq /iv/stat slow given 

Grbs : 56 mg/dl 

IVF - 25% Dextrose given

PR - 86 /min rate again increased and reverted to SVT in 10 mins 

Bp - 100/60 mm hg 

Pr - 84 / min ,rate again increased and reverted to SVT in 10 mins(PR>180 )

BP : 100/40 mmHg 

Inj.DILTIAZEM 25 mg /IV/STAT 

Bp : 60 systolic 

Spo2 : 95%on RA

PR: 86/min

 Abg : 

pH - 7.094

pCo2 - 31

PaO2 - 61 

HCo3 - 9.2 

In v/o gasping state with GCS - 3/15 

With ABG showing type 1 respiratory failure .pt was intubated with ET -6.5 MM 

after giving inj.vecuronium 4 mg ,inj.glycopyrolate 2cc/iv/stat and connected to mechanical ventilator acmv mode

RR=16/min. Acmu -ve

UT=380ml

PEEP : 5mm H2O

In v/o hypotension post intubation,

ABG showing 

pH - 6.951 

pCo2 - 49.2

pO2 - 379

SpO2 - 96.7%

HCo3(stat)- 9.1

HCo3(c)-10.3

Pt. was started on

Inj NORAD -DS@ 8ml/ hr

Inj.Dobutamine @ 4ml/ hr

Plan for thriple lumen catheter.

CAUSE OF DEATH : 

  NSTEMI

Refractory hypotension secondary to myocardial depression secondary to severe metabolic acidosis

Svt (resolved)

Antecedents- 

Antecedantal : hypokalemia and severe metabolic acidosis secondary to ureterosigmoidostomy

With pre renal Aki secondary to ge