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case of Cardiogenic shock

 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".
  This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome.


Name : Kattekola Sathwik

Roll no: 58

8th semester


Case details 


An 87 year old male patient has presented with the complaints of shortness of breath since 3 days constipation since 3 days decreased urine output since 2 days


History of present illness

The patient was apparently asymptomatic 3 days ago then he developed shortness of breath which was sudden onset and he went to an RMP doctor who administered IV fluids following which he felt better.

No history of chest pain fever cough

Also had history of constipation 3 to 4 days with abdominal distension and had an episode of vomiting the previous day. Also there was a decrease in his appetite


He also complained of decrease urine output from two days

 H/O  Whitish discharge in urine.

There was no history of pain abdomen


History of past illness

TURP + Exploratory Laparotomy for BPH and B/L renal calculi -2yrs  ago



PERSONAL HISTORY 

Appetite: decreased

diet: mixed

Bowel and bladder :Decreased urine output and constipation

sleep :adequate

addictions: 

  • occasional alcoholic 
  • smoker: 4-5 beedis per day since 30 years but stopped about 2 years ago


FAMILY HISTORY : Insignificant


GENERAL EXAMINATION

The patient was examined in a well lit room after obtaining a valid consent
he was conscious ,coherent, cooperative
well oriented to time place and person
Pallor : present
Icterus:absent
Clubbing:absent
Cyanosis:absent
Lymphadenopathy :absent
Pedal edema:absent 

Vitals
Temperature: afebrile
Respiratory rate: 20cpm
Pulse rate:44bpm
Blood pressure:80/60mmHg


EXAMINATION OF CARDIOVASCULAR SYSTEM

  • no thrills
  • s1 and s2 heard 
  • no murmurs

EXAMINATION OF RESPIRATORY SYSTEM

  • Bilateral air entry present and vesicular breath sounds heard
  • Dyspnea seen
  • Trachea is central in position

Per abdomen

  • Distended abdomen
  • No tenderness
  • Bowel sounds heard

COURSE IN HOSPITAL

 The patient was admitted in the ward.
Advice regarding foley's catheterization  for 14 days was is obtained from the Department of Urology

Key points from cross consultation
  • Foley's catheterization was attempted by local RMP
  • Feeding tube number 10 was inserted but slipped out
  • Foley's catheterization  with 14F foley's catheter done 
  • Advised USG-KUB
INVESTIGATIONS 

RENAL FUNCTION TESTS

  • UREA: 222
  • SERUM CREATININE:4.3
  • Na:133 mEq/L
  • K: 5.9
  • Cl: 103
HEMOGRAM

  • Hb:11.9g
  • TLC:18,000
  • PLATELET: 1.2L
RBS: 147mg/dL

SERUM Mg+: 1.8mg/dL

PT: 16 sec

aPTT: 32sec

INR: 1.11

D-DIMER: 31400ng/ml

ABG

  • pH:7.2
  • PCO2 : 19mmHg
  • PO2: 76.9 mmHg

ECG 

        Day 1


 

        Day 2

 


       

2D ECHO




Diagnosis

CARDIOGENIC SHOCK SECONDARY TO  ANTERIOR WALL MI WITH HFrEF AND CARDIORENAL SYNDROME 

Treatment

DAY 1
  • INJ  DOBUTAMINE  2.5mcg/kg/min [125mcg/min] 1 ampoule in 50 ml NS
  • INJ HEPARIN   
  • INJ PAN 40mg OD
  • T.ECOSPIRIN  150mgOD
  • T.CLOPITAB  75 mg OD
  • T.ATORVAS  40mg OD
  • T.DYTOR    10mg OD
  • SYP.  LACTULOSE 10ml/PO/HS
DAY 2
  • INJ. DOBUTAMINE  2.5mcg/kg/min [125mcg/min] 1 ampoule in 50 ml NS 
  • INJ.HEPARIN  
  • INJ.PAN  40mg OD
  • INJ.CEFTRIAXONE 1g iv BD
  • T.ECOSPIRIN  150mg OD
  • T.CLOPITAB  75MG OD
  • T.ATORVAS  40MG
  • SYP.LACTULOSE   10ml/PO/HS
  • T.DYTOR  10mg OD
DAY 3
  • INJ.DOBUTAMINE 2.5mcg/kg/min [125mcg/min] 1 ampoule in 50 ml NS
  • INJ.HEPARIN  
  • INJ.PAN 40mg OD
  • INJ.CEFTRIAXONE 1g iv BD
  • T.ECOSPIRIN 150mg OD
  • T.CLOPITAB  75MG OD
  • T.ATORVAS  40MG
  • SYP.LACTULOSE   10ml/PO/HS
BP/PR/TEMPERATURE MONITORING 
STRICT I/O CHARTING
GRBS CHARTING



At about 3:50 p.m. on day 3 of hospital stay the patient has become unconscious suddenly with BP and pulse rate not recordable. Immediate CPR was initiated as per AHA guidelines.

In spite of all the necessity is measures taken the patients was not revived and ECG has shown a flat isoelectric line and the patient was declared dead at evening 4 :22 p.m. on day 3 of hospital stay.



Immediate cause of death: cardiogenic shock secondary  to Acute AWMI

Antecedent cause:  HFrEF  with  cardiorenal syndrome



























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