This is online E log book to discuss our patient's de-identified health data shared after taking 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 .This e-log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome.
About the patient :
ECG @ time of Admission
2D Echo :
The patient is a 32 year old man hailing from the southern part of India , who is a Lorry driver by occupation presented to the casualty on 25/May/2021 with complaints of
Pain Abdomen since 3 days which has become extreme with passing time
constipation since 3 days
Vomiting Episodes since 2 Days
Shortness of Breath since 1 day
Elaborating on his Chief Complaints :
The Patient is a heavy alcoholic for the past 15 years, he was apparently fine 5 years ago when he had an attack of Acute Pancreatitis , from which he recovered with treatment .
He did not bring any changes to his Alcohol intake ;
began experiencing Abdominal Pain since the past 3 days
Pain is in the upper abdomen (Epigastric Pain) , dull in nature , radiating to the back
Vomiting Episodes have been 2-3 times a day for the past 2 days, contents of Vomitus is Food.
Shortness of Breath is of Grade 1 ; since the past day.
Past History :
The patient has a history of pacreatitis 5 years ago.
Not a known case of DM , HTN .
Has not had TB, Epilepsy , Asthma
Personal History :
He has Normal Appetite ,
takes mixed Diet
His Bowel and Bladder movements are normal and regular ( but patient complains of having constipation since the past 3 days )
no known Allergies.
Hand Written Notes on History :
ADDICTION DETAILS :
The patient uses chewable Tobacco.
He is an alcoholic for the last 15 years.
Consumes 5-6 full bottles of alcohol in a week.
volume of intake : ( 750 * 6 ) ml
Initial Assessment Notes: 
FINDINGS OF THE PATIENT ON PRESENTATION
Vitals :
Pulse :
Rate : 130 bpm
Rythm : regular
Volume : Adequate
Condition of Vessel : Normal
Delays : absent.
Blood Pressure :
Value : 130/90 mm Hg recorded on the Right Arm ( Brachial Artery )
Postion : Supine
Respiratory Rate:
24 cps
Spo2 : 97 % on room air
Pain : Present
( 8 on Wong Baker Faces Pain scale )
GENERAL EXAMINATION :
Mild Dehydration
Systemic Examination :
Abdomen : Tenderness and rigidity in the epigastric and hypochondriac region ;Sluggish Bowel Sounds.
SIGNS: Cullen's Sign ; Fox's Sign , Grey turner 's Sign were negative.
REPORTS SHOWN AT THE TIME OF PRESENTATION :
CECT :
Pancreatitis
Mild Ascites
B/L Mild pleural Effusion
with Consolidative lesions in B/l lower lung lobes.
CTS :8/10
USG : Grade 1 Fatty Liver ; Pancreatitis
Blood Works :
Hb : 14.6
TLC : 17500
Platelet : 2.32
Serum Amylase :271
Serum Lipase :137
Chest X Ray @ time of Admission
INTERVENTIONS DONE IMMEDIATELY AFTER THE PATIENT PRESENTED :
Analgesia
Fluid Rescusitation
Ultrasonogram Findings ( done after admission ) :
- Body of Pancreas Edematous with Altered Echotexture
- Peripancreatic Fluid Accumuation seen
- Mild Ascites
- B/L Pleural Effusion
- Grade 1 Fatty Liver
2D Echo :
OTHER CRISIS EVENTS WHICH FOLLOWED IN THE PATIENT :
TIMELINE :
25/May /2021 12:30 pm :
Patient began having Tachycardia , Tachypneoa , with Hypoxia.
Diagnosed with Supraventricular Tachycardia.
Refractory to Vagal Manouvres
Refractory to Adenosine
Patient was electively intubated in view of ARDS and administered Amiodarone.
Plain Chest Radiograph : Post Intubation
25/May/2021 6:30 pm :
Patient developed Hypotension
Ionotropic support given.
Amiodarone infusion continued in lieu of Arrythmia .
D Dimers levels elevated .
Anticoagulation started .
26/May/2021 1:00 am :
Patient suddenly developed Bradycardia with fall in Oxygen Saturation ( 48 % )
Central Pulses not felt
CPR done in accordance with ACLS guidelines inspite of which he could not be rescusitated ,
Declared dead at 1:53 am.
ECG @ 26/May/2021 1:53 am
ECG STRIPS : 
25/May/21 1:30 pm
25 May 2021 2:37 pm
25/May/21 2:38 pm
25/May/2021
7:00 pm
no electical activity
26/May/2021
1:53 am
OUTCOME : 
Immediate Cause of Death : Pulmonary Embolism
Antecent Cause of Death : Severe Acute Pancreatitis ; ARDS
Corelation Of Pulmonary Embolism in Patients of Pancreatitis :
- Discussion :
Why were the signs ( indicating Coagulopathy ) absent in the patient who developed a massive coagulopathic crisis later ?
What could have been done pro actively to forsee the DIC ?
What could have been the appropriate Ventilator Settings used in this patient ?
No comments:
Post a Comment