75 year old female patient with hypovolemic shock /(?) cardiogenic shock with type 1 respiratory failure and severe metabolic acidosis .

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NAME :: M.VARUN SAI

ROLL.NO. :: 73 

BATCH :: 2017

A 75 year old female patient was brought to the casualty with chief complaints of 

 # FEVER since 4 days .

 # GENERALISED WEAKNESS since 3 days .

 # VOMITING since 3 days .

 # SHORTNESS OF BREATH since 1 day.

History of presenting illness :

Patient was apparently asymptomatic 3 months back and is able to do her regular work at home. 

 she developed shortness of breath of grade 3 along with dizziness and generalised weakness which made her to fall for which she was taken to a local hospital in hyderbad , MRI was done which showed no abnormality and  used medications for the above. There were no similar episodes when on medications. 

4 days back she developed fever which was low grade , intermittent, not associated with chills and rigor , no diurnal variation , relieved on medications. 

2 days back she developed vomitings of 4 episodes which were non projectile , food particles as content , non bilious , non foul smelling and associated with loss of appetite ( patient's attender gives the history that she often forgets to eat food )not associated with loose stools and pain abdomen. 

She developed shortness of breath since morning which was grade 3 not associated with chest pain , palpitations, orthopnea and paroxysmal nocturnal dyspnea .

Past history ::

No similar compliants in the past and no previous hospitalization.

Not a known case of diabetes , hypertension, asthma , Tuberculosis and epilepsy. 

No past surgeries and blood transfusion.

 

Personal history ::

Appetite is decreased.

Mixed diet.

Sleep adequate .

Bowel and bladder regular .

No known food and drug allergies.

No addictions.

Family history ::

Not significant.

GENERAL EXAMINATION ::

* The patient is conscious , non coherent and non -cooperative .

* Moderately built and moderately nourished.

Examined the patient in supine position and in well lit room.

* Pallor : Absent 

* Icterus : Absent

* Cyanosis : Absent

* Clubbing : Absent 

* Lymphadenopathy : Absent

* Edema : Bilateral, pitting type upto thighs 

VITALS ::

Temp: Afebrile 

PR: 78 Beats per minute , low volume pulse , normal character and rythmn and vessel wall normal .

BP: could not be measured.

RR: 28 cycles per minute.

Spo2 - 50% at Room air. 85% at 15 litres of oxygen.

GRBS- 43 mg/dL.

SYSTEMIC EXAMINATION ::

* RESPIRATORY SYSTEM : Normal Vesicular Breath Sounds Audible, Position of trachea is central, Bilateral air entry present

* CVS : S1 and S2 Heard, no murmurs, no thrills

* CNS : Higher mental functions normal , Cranial nerves: intact, No meningeal signs, GCS- 15/15 , deep tendon reflexes are normal , sensory system intact.

* PER ABDOMEN : scaphoid shape, Abdomen not distended with no scars, sinuses, engorged veins , No tenderness, No palpable mass, normal hernial orifices , Bowel sounds heard.

 

DIFFERENTIAL DIAGNOSIS ::

? Hypovolemic shock/cardiogenic shock. ? Starvation ketoacidosis.

? Toxic ingestion.

PROBABLE PATHOGENESIS FOR THE DISEASE ::

INVESTIGATIONS ::

ARTERIAL BLOOD GAS ::

RENAL FUNCTION TEST ::

LIVER FUNCTION TEST ::

BLOOD SUGAR & BLOOD UREA ::

ECG ::

Chest X Ray ::

Findings :: cardiomegaly.

PROVISIONAL DIAGNOSIS ::

 HYPOVOLEMIC SHOCK/ (?) CARDIOGENIC SHOCK   with type I RESPIRATORY FAILURE and SEVERE METABOLIC ACIDOSIS.

TREATMENT ::

1. 30 Normal saline bolus i.v.

2. 10 Normal saline infusion at 100ml/hr.

3. Injection Nor adrenaline ( 20mg + 30ml Normal saline ) at 8ml/hr. Increase or decrease the dose as required to maintain mean arterial pressure more than 65mm of Hg .

4. Oxygen inhalation to maintain saturation.

5. Patient was intubated around 7.30 pm on 11/01/2022 .