MEDICINE CASE DISCUSSION
30 years old male with Type 2 Respiratory Failure secondary to aspiration pneumonia
Feb 14, 2022
P.Manasa
9th semester
Roll no:- 102
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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.
CASE
30 years old male working as farmer came to our casualty at 9:15 AM on 13/2/2022 with the chief complaint of dyspnoea since 2 hours and and nausea since 2 hours
HOPI:
Patient is the father of two girls is an alcoholic since past 5 to 6 years with a intake of 90 to 180 ML of whiskey every day .
yesterday night he consumed 90 ML of whiskey following which the patient complained of generalised weakness and 5-6 episodes of loose stools .
At 4 AM in the morning patient was hungry so he was given milk when he was in supine position by his attender (mother) Following which the patient started to complain of nausea .had vomiting which is white froathy non projectile and he become tachypneic
H/o Intake of herbal medication for one day For alcohol dependence syndrome
PAST HISTORY:
3yrs back his mother wanted him to stop drinking and admitted in private hospital for 20-25 days. After 5-6 days of comming from hospital he started drinking again.
Not a known case of DM, HTN,TB,epilepsy, CAD, CVA.
PERSONAL HISTORY :
Diet : mixed
Appetite : normal
Bowel and bladder moments : regular
Habits/addictions : he Is alcoholic since six years daily intake of whiskey 90 to 180 ML per day.
He chews tobacco one pack for day.
FAMILY HISTORY :
No significant family history
GENERAL EXAMINATION:
Patient is conscious, coherent , cooperative
No signs of pallor , icterus, clubbing , Sinuses lymphadenopathy , pedal edema.
VITALS :
13/2/22 14/2/22
Temp : Afebrile. Afebrile
Bp : 150/90 mmHg. 180/100mmHg
Pr : 120 bpm. 110bpm
Rr : 20 cpm. 22cpm
Spo2 : 98% at ra
Grbs : 210mg% 113mg%
Systemic Examination :
Cardiovascular system : s1 , s2 heard , no murmur
Respiratory system : b/L respiratory crepts in all lung fields.
Per abdomen : soft , non-tender , no organomegaly.
INVESTIGATIONS:
HEMOGRAM:
HB: 17.9
TLC: 4,000
N/L/E/M/B: 85/10/01/04/00
PCV: 53.4
MCV: 90.1
MCH: 30.2
MCHC:33.5
RBC:5.93
PT:2.06
RDW-CV :12.8
RDW-SD: 42.5
PS: NC/NC
RFT:
BLOOD UREA : 21mg/dl
SERUM CREATININE: 0.8 mg/dl
SERUM ELECTROLYTES:
Ca : 9.6
Na+ : 144
K+: 4.0
Cl-: 100
LFT
TB: 1.44
DB: 0.65
SGOT:40
SGOT:15
ALP: 169
TP:7.3
ALBUMIN:3.6
A/G: 1.36
Rbs : 125
Serum osmolality : 302.4
Serology : negative
Complete urine examination :
Albumin : 3+
Sugar : 2+
13/2 14/2. 15/2
18.27 4.36. 5.01. 14.37. 7.27
PH:. 7.2 7.5. 7.3. 7.2 7.5
PCO2:. 48.5. 47.4. 37.8. 21.5 31.2
PO2:. 250.7. 62.4. 101.5. 137.9 93.2
HCO3 act:. 10. 38.2. 20.4. 9.5
HCO3std:. 18.4 37.6. 20.7. 11.9
Na+:. 139.7. 118.3. 138.7. ?
K+:. 4.35 2.66. 3.64. 5.76
Ca+:. 4.7. 1.3 4.5. Decrease
Cl:. 105. 81. 105. Decrease
Anion gap: 19.1. 1.8. 17.
Glu:. 128. 85. 105. 62
Lac:. 1.78. 0.62. 1.22. 1.33
Provisional diagnosis : type2 respiratory failure secondary to ?aspiration pneumonia
Treatment:
1) head end elevation
2) inj.piptaz 2.25gm/iv/6th hrly
3) Nebuliaztions with mucomist 4th hrly and budecort 6th hrly
4) chest physiotherpay 12th hrly
5) inj.thiamine 1amp in 100ml Ns/iv/tid
6) monitor vitals hourly - bp,pr,spo2,rr
7) frequent suctioning of oral and nasal secretions
