Cor pulmonale with type 3 PAH with type2 respiratory failure ? COPD with denovo DM 2

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

47 yr old male came to casualty with c/o SOB , cough with sputum since 4days .

HOPI-

Pt was apparently asymptomatic 15yrs back had intermittent SOB (grade 2) assoc. with cough with sputum (?asthma ) for which pt was on intermittent inhalers .

3yrs back had H/o pedal oedema , SOB (grade-4) with orthopnea , abdominal distension , consulted the cardiologist , said to have CAD , patient was on TAB.frusemide , TAB PAH(20 mg) , Echo shows : RA , RV dilated with EF 50%.Patient was on irregular medication for CAD and Right heart failure with PAH.

4days back had H/o pedal oedema , abdominal distension, SOB(grade-4), decreased response , not responding to deep stimuli . Admitted in outside hospital with SpO2 :80 @ RA, RR:38/min . Patient was put on Inj.NA & dobutamine , O2 inhalation & intermittent BiPAP , Inj. Zostrutum, Inj thiamine  

Past History :

Not a k/c/o HTN,DM,TB, Asthma, CAD, CVD

Personal history :

Diet-mixed 

Appetite - normal 

B&B - regular 

Family  history -not significant

On Examination :

Patient is 

Afebrile 

BP- 90/60 mmHg

PR- 87bpm

SpO2-93%@RA

Systemic examination :

CVS - S1  S2 +  , No murmurs 

RS- B/L crrpts + in IAA ,IMA ,ISA

P/A - soft , non tender , BS +

CNS - NAD

Provisional diagnosis:

Right heart failure with CAD with denovo DM type 2

Investigations :

8/12/21

9/12/21

10/12/21

11/12/21

12/12/21

12AM

4:30 AM

8PM

11PM

13/12/21

2AM

   6:30AM

14/12/21

3AM

6AM

11AM

3pm

8pm

15/12/21

12:30 AM

6AM

11AM

3PM

Treatment history: 

1.Head end elevation 

2.O2 inhalation to maintain SpO2

3.Inj. Lasix 40mg IV/BD (if SBP

4.Inj. pantop 40mg IV /BD

5.Nebulisation with budecort -12th hrly , duolin -8th hrly .

6.Tab. metformin 500mg PO / BD 

7. I/O , temp monitoring 

8. Weight monitoring - daily 

SOAP notes :

DAY1

S- sob decreased 

Cough with sputum +

No fever spikes

Passed stools yesterday

O- pt is conscious,coherent 

Afebrile

PR 94/min

Bp 110/80 mmhg

RR 22 cpm

Spo2 96%

Cvs s1s2 +

Rs b/l air entry+,b/l basal crepts +

P/a soft, non tender

Grbs 174 mg/dl

I/o 1000/2000

pH -7.35----7.38----7.41----7.38

Pco2-131--110----117-----137

Po2---340---68.6--62.1---83.6

Hco3--70.5--64.4--74---80.2

St.hco3--61.9--56--66.2--72.3

O2 sat--99.4---92--90---95.2

A- Corpulmonale with type 3 pulmonary arterial hypertension 

Severe respiratory acidosis

bronchial asthma

Denovo diabetes 

P- NIV with bipap continously

Neb with duolin ,mucomist tid,Budecort bd

Chest physiotherapy

Inj Augmentin 1.2 g iv bd

Inj hai s/c tid according to grbs

Monitor vitals

http://snehakalyankar.blogspot.com/2021/12/right-heart-failure-with-cad-with.html

DAY2

S- sob decreased 

Cough with sputum +

No fever spikes

Not Passed stools 

O- pt is conscious,coherent 

Afebrile

PR 96/min

Bp 130/80 mmhg

RR 20 cpm

Spo2 96%

Cvs s1s2 +

Rs b/l decreased breath sounds+

P/a soft, non tender

Grbs 101 mg/dl

I/o 800/1000

pH -7.35----7.38----7.41----7.38

Pco2-131--110----117-----137

Po2---340---68.6--62.1---83.6

Hco3--70.5--64.4--74---80.2

St.hco3--61.9--56--66.2--72.3

O2 sat--99.4---92--90---95.2

A- Corpulmonale with type 3 pulmonary arterial hypertension 

Severe respiratory acidosis

bronchial asthma

Denovo diabetes 

P- NIV with bipap continously

Neb with duolin ,mucomist tid,Budecort bd

Chest physiotherapy

Inj Augmentin 1.2 g iv bd

Inj hai s/c tid according to grbs

Monitor vitals

Day 3

S- pt on mechanical ventilator day 2

No fever spikes

Not Passed stools 

O- pt on mechanical ventilator

ACMV VC mode

Rr-15

Vt-400

Peep-8

Fio2-40%

On inj vecuronium 1mg/ml/hr,midazolam 30mg/hr infusion 

Afebrile

PR 96/min

Bp 120/80 mmhg 

RR 20 cpm

Spo2 96%

Cvs s1s2 +

Rs b/l decreased breath sounds+

P/a soft, non tender

Grbs 205 mg/dl

I/o 1300/700

A- Corpulmonale with type 3 pulmonary arterial hypertension 

With type 2 respiratory failure

Severe respiratory acidosis

With ?copd

Denovo diabetes 

P- Neb with duolin ,mucomist tid,Budecort bd

Frequent Et and oral suction 

Chest physiotherapy

Inj Augmentin 1.2 g iv bd

Inj hai s/c tid according to grbs

Rt feeds 4th hrly

Monitor vitals

I/o charting

Day 4

S- pt on mechanical ventilator day 3

No fever spikes

O- pt on mechanical ventilator

ACMV VC mode

Rr-15

Vt-400

Peep-5

Fio2-70%

On inj vecuronium 4mg/hr,midazolam 10mg/hr and fentnyl 6 ml/hr infusion 

Afebrile

PR 94/min

Bp 90/60 mmhg 

RR 15 cpm

Spo2 96%

Cvs s1s2 +

Rs b/l air entry +

P/a soft, non tender

Grbs 146 mg/dl

I/o 3000/2500

A- Corpulmonale with type 3 pulmonary arterial hypertension 

With type 2 respiratory failure

Severe respiratory acidosis

With ?copd

Denovo diabetes 

P- Neb with duolin ,mucomist tid,Budecort bd

Frequent Et and oral suction 

Chest physiotherapy

Inj Augmentin 1.2 g iv bd

Inj hai s/c tid according to grbs

Rt feeds 4th hrly

Monitor vitals

I/o charting

Day 5

S- pt on mechanical ventilator day 4

fever spikes + yesterday 

O- pt on mechanical ventilator

ACMV VC mode

Rr-18

Vt-400

Peep-5

Fio2-70%

On inj vecuronium 4mg/hr,midazolam 2mg/hr and fentnyl 2 ml/hr infusion 

Afebrile

PR 92/min

Bp 100/60 mmhg 

RR 18 cpm

Spo2 96%

Cvs s1s2 +

Rs b/l air entry +,b/l basal crepts+

P/a soft, non tender

Grade 1 bed sore +

Grbs 286 mg/dl

I/o 1700/900

A- Corpulmonale with type 3 pulmonary arterial hypertension 

With type 2 respiratory failure

Severe respiratory acidosis

With ?copd

Denovo diabetes with grade 1 bed sore

P- Neb with duolin ,mucomist tid,Budecort bd

Frequent Et and oral suction 

Chest physiotherapy

Frequent change of position

Inj meropenem 1 g iv bd

Inj hai s/c tid according to grbs

Rt feeds 4th hrly

Monitor vitals

I/o charting

Day 6

S- pt on mechanical ventilator day 5

fever spikes + yesterday 

O- pt on mechanical ventilator

ACMV VC mode

Rr-20

Vt-360

Peep-4

Fio2-60%

On inj vecuronium 4mg/hr,midazolam 2mg/hr and fentnyl 10 ml/hr infusion 

Afebrile

PR 88/min

Bp 90/60 mmhg 

RR 20 cpm

Spo2 96%

Cvs s1s2 +

Rs b/l air entry +, crepts+ in b/l basal ,rt infraclavicular areas

P/a soft, non tender

Grade 1 bed sore +

Grbs 296 mg/dl

I/o 2400/3000

A- Corpulmonale with type 3 pulmonary arterial hypertension 

With type 2 respiratory failure

Severe respiratory acidosis

With ?copd

Denovo diabetes with grade 1 bed sore

P- Neb with duolin ,mucomist tid,Budecort bd

Frequent Et and oral suction 

Chest physiotherapy

Frequent change of position

Inj meropenem 1 g iv bd

Inj hai s/c tid according to grbs

Rt feeds 4th hrly

Monitor vitals

I/o charting

Day 7

S- pt on mechanical ventilator day 6

fever spikes + 

O- pt on mechanical ventilator

ACMV VC mode

Rr-20

Vt-360

Peep-5

Fio2-70%

On inj vecuronium 4mg/hr,midazolam 6mg/hr and fentanyl 15 ml/hr infusion 

Afebrile

PR 86/min

Bp 140/80 mmhg 

RR 20 cpm

Spo2 97%

Cvs s1s2 +

Rs b/l air entry +, crepts+ in b/l basal ,rt infraclavicular areas

P/a soft, non tender

Grade 1 bed sore +

Grbs 231 mg/dl

I/o 3500/1950

A- Corpulmonale with type 3 pulmonary arterial hypertension 

With type 2 respiratory failure

Severe respiratory acidosis

With ?copd

Denovo diabetes with grade 1 bed sore

P- Neb with duolin ,mucomist tid,Budecort bd

Frequent Et and oral suction 

Chest physiotherapy

Frequent change of position

Inj meropenem 1 g iv bd

Inj hai s/c tid according to grbs

Rt feeds 4th hrly

Monitor vitals

I/o charting