A 39 year old unconscious male
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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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
A 39 year old male came to casualty with chief complaints of pedal edema ,shortness of breath and retrosternal chest pain since 15 days
history of present illness : Patient was apparently asymptomatic 15 days ago then he developed shortness of breath by doing his ordinary routine activity(described in personal history) (grade 2) associated with pedal edema ,pitting type ,upto ankle and he got retrosternal chest pain which is sudden in onset, constant pain, non radiating and partially relieved by medication ,sweating?exaceberated on taking alcohol.On 10 July, they went to other hospital ,as the treatment doesn't improve ,the pain is severe,he has been shifted and presented in a unconscious state to our hospital,after 2 cycles of cpr patient has been revived and intubated.
PAST HISTORY: patient has similar episode 5 years ago with shortness of breath,pedal edema and chest pain .
NO history of diabetes,hypertension ,asthma,TB,epilepsy.
PERSONAL HISTIORY: patient is a scrap,second hand item dealer,he also repairs stoves ,goes to agriculture lands to shift the rice bags and also do field work.
patient usually gets up at 7 O clock , he ,pulls a trolley, goes to house to house and collects old items and scrap and gives new items as a deal ,at 11 O clock he goes to abarsbop drinks 90ml of alcohol and comes to home and eats which is both non veg and veg . From afternoon, he separates the old items until 6 O clock,he usually smokes at this time .Evening times, he again goes out with friends and drinks 180 ml of alcohol and come home at 10 o clock and sleeps .
Alcohol history: AUDIT C SCORE MORE THAN 3
He drinks whisky about 270 ml per day ,varies according to money he collected that day from past 7 years after his first girl child marriage. Before 7 years he is a occasional drinker ,drinks 90ml.per day from 20 years.
5 years ago, he had attack of similar episode ,then he stopped drinking alcohol for 1 year and again he continued gradually, there is no physical dependence. (no biological signs such as sweats,tremors and fits)and has psychological dependence ,he feels compulsion to drink and beg relatives for money.
Health attitude: if he gets fever ,he usually drinks alcohol to subside it. Daily by walking long lengths, he gets sob to subside it ,he drinks alcohol,he doesn't even stop after chest pain which is mild.
His diet is negatively affected, he usually eats once daily from past 5 years.
Tobacco history: 15 beedis per day from past 10 years.
GENERAL EXAMINATION: patient is unconscious,
GCS score: E2,VT,M4.
response to pain ( deep pain at sternum) ,where the movement doesn't reach the area of painful stimuli- non purposeful movement
No pallor icterus cyanosis clubbing and lymphadenopathy,edema subsided.
pupil: normal size, sluggishly reacting to light
corneal reflex: brisk on both sides
conjunctival reflex : positive n both sides
oculocephalic reflex(DOLLS EYE PHENOMENON): negative, doesn't move to opposite side when rotated.
bilateral abductor palsy( highest intracranial course)(false localizing sign) raised ICT.
motor system
tone normal
power: +3, as he is moving his limb to pain
reflexes : plantar reflex -mute
knee jerk-1+ ,slight response
no pedal edema
right eye ,redness in inferior conjunctival fonix
VITALS:
pulse:65bpm,low volume
Bp:110/60 mmhg
respiratory rate:16cpm
temperature:99 degree F
CVS EXAMINATION:
INSPECTION: ecg leads placed on,jvp cant be seen
Palpation: apex beat is at 6th intercoastal space and lateral to mid clavicular line .
Auscultation: s1,s2 heard,no murmurs
Respiratory system:
INSPECTION: normal
palpation:trachea central
percussion :resonant to 8 areas other areas cannot be asssessed
auscultation:normal vehicular breath sounds in supra and infraclavicular,mammary and infra mammary.
Abdominal examination:soft non tender,bowel sounds are heard.
INVESTIGATIONS:
on 15/7/22
63bpm
narrow qrs complex <3small boxes
depolarization :septal v1 negative q wave ,v5v6 position r wave
free wall: v1 positive r wave ,v5,by negative s wave
p wave : 2.5mm ×2.5mm
long pr interval(>200ms) - 7 small boxes
no axis deviation
ST RELATED CHANGES: st depression inverted twaves in V1,V2,V3,V4.
TWAVE:
on 15/7/22 8:50pm
troponin I: 517pg/ml
CBP:
nlratio -6.15-a prognostic marker
RBC: high rdw-CV a prognostic marker
normal cue
LIVER FUNCTION TESTS
on 15/7/22
AST/ALT:1.8:1- alcoholic liver disease
on 18/7/22
total bilirubin:2.72
direct bilirubin:1.00
sgpt:10
sgot:13
alkaline phosphatase:103
total proteins:5.3
albumin:3.1
A/G ratio:1.44
RENAL FUNCTION TESTS:
on 15/7/22
ECHO:
DIAGNOSIS: cardiogenic shock secondary to cad(NSTEMI),post cpr status, with aki and ari
TREATMENT :
on ventilation
simv-VC mode
USG ABDOMEN FINDINGS:
MRI
TREATMENT PLAN:
PROGNOSTIC MARKERS:
uric acid to albumin ratio
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8280454/
neutrophil to lymphocyte ratio
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026362/#:~:text=The%20NLR%20ranges%20from%200.50,with%20myocardial%20function%20(NLR%20vs
red cell distribution width
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606102/
QUESTIONS
Echo findings are not correlating with history and clinical findings
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