58F METABOLIC SYN, OSA,CUSHINGS, RIGHT LEG PAIN, STEROIDS 3YRS,SOB, IPPV 1 DAY. TELANGANA. PAJR

09-11-2024

This is an online E Log book to discuss our patient's de-identified health data shared after taking her signed informed consent.

Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. 

The patient is a 58 Yr old female developed sudden giddiness with deviation of mouth to left side and with snoring was being taken to a nearby hospital and on the way she had clinching of fist for 10 minutes. Later she was brought to our hospital. 

CHIEF COMPLAINTS 

C/O Unresponsiveness since morning. 

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 1 day before after which she developed sudden giddiness,  then deviation of mouth to left side and started snoring.  She was being taken to a nearby hospital and on the way she had clinching of fist for 10 min and afterwards brought to  our hospital. During which she developed rise in body temperature suddenly and gradually progressed.

HISTORY OF PRESENT ILLNESS 

C/O Tongue bite for 10 min, 11hrs back.

No C/O involuntary micturition,  defection uprolling of eyes.

No H/O Polyuria, Polydypsia,  Polyphasic.

No Cyanosis 

No H/O facial puffiness 

No H/O abnormal sweating. 

HISTORY OF PAST ILLNESS 

H/O Cellulitis to right leg since 2yrs(on and off 3 times)

H/O CVA 6 months 

ASO deviation of mouth to left

H/O usage of inhaler since 10yrs  occasionally,  especially in winter.

K/C/O HTN ? Yrs on Tab.Telma H 80/12.5mg PO/OD 

Tab.MetXL 500mg  PO/OD 

N/K/C/O DM, TB, Thyroid,  CVA, CAD.

PPM 1 - Current Stats

Heart rate- 135

Spo2 - 99

Ventilator set respiratory rate  - 14.

How much Fio2 is she on? @ PPM 3?

Please share her chest X ray  and available serial ABGs.

PPM 3 - Sir now on Fio2 =50

PPM 1 - 👍  Please share her chest X ray  and available ABGs. Any other investigations  that are available. 

PPM 3 - 

PPM 1 - Cardiology  suggesting of Chronic heart failure.  Would be nice to see her echocardiography video. 

PPM 3 -

PPM 1 - Do we have a pre intubation ABG?

PPM 4 - Pre intubation  ABG  sir.

PPM 1 - What is the reason for her Metabolic acidosis? What's her Serum Creatinine?

PPM 5 - 1.7.

@PPM3 Please share the I/O since admission. 

PPM 1 - 👍 

PPM 3 - Post intubation  ABG 

PPM 1 - Can reduce her Fio2  as it may further her type 2.

PPM 5 - @PPM3 Sir update the current  ABG. I/O from 11am 1800/300.  At 6pm BP  was 80/40 sir. 200ml  0.9 NS bolus was given. BP since then 90/60mmhg

PPM 1 - 👍  Metabolic syndrome with lot of comorbidities. 

PPM 4 - Now ABG increasing Fio2  to 60

10-11-2024

PPM 2 - This is likely  a VBG. The PO2  and the Lactate don't  add up. Should have very low threshold for Adrenal insufficiency especially in patients with exogenous  Cushings  as they become cushingoid due to steroid excess but the chronic steroid use put their HPA axis to sleep and once inter current  illness sets in Adrenal crisis shows. 

Yes just saw that this cushings  is due to exogenous steroids.  I would recommend considering Hydrocort supplementation.  What's the reason for intubation?

PPM 1 - 👍  👏👏 Good point.  @PPM3 Let's  start her on IV Hydrocortisone 100mg  6 hrly if not done already. Done in casualty.  @PPM3 please share the casualty notes that mention  the indication  for intubation. 

PPM  2 - What is her baseline Sodium?

PPM 1 - @PPM3 please share. No Lactate measured here.

PPM 6 - 

PPM 2 - 0.3 Lactate @PPM1.

Interesting that nothing here is suggestive  of Adrenal insufficiency. 

PPM 1 - 👍 

PPM 2 - Although the X ray hardly explains the Type 2 respiratory failure. Neuro muscular weakness? Alongwith heart failure?

PPM 1 - 👍  Oh! I saw the Lactate in this last ABG @PPM2.  Yes many of our type 2 are heart failure  with chest muscle  fatigue,  which is when they start gasping. 

Oh! now I remembered,  this patient  was  intubated outside?@PPM3 can you share the outside intubation notes?

I think we need to formally publish our dats on LVF and type 2 respiratory failure  as we now have quite a lot of them in our case reports  data base. @PPM6  what are the stats this morning? I guess stats is a medical  colloquial term for patient  data particularly used in critical care settings. 

ICU 2 Yesterday's PaJR  initiation stats maintained since yesterday. 

Predominant hypothesis  is:

Metabolic syndrome with LVF and multiple  other comorbidities  such as Iatrogenic  Cushings!

Serial ABGs. 

Vitals.

PPM 3 - 👆History.

10-11-2024 

PPM 1 - Are we planning hemodialysis today evening  in this patient?

PPM 6 - Yes sir 

PPM 1 - Please share her updates. 

PPM 3 - Her ABG  today I/O from morning  - 1050/100

PPM 1 - Serum Creatinine? Any wearing trial with withdrawal of sedation?

PPM 3 - Creatinine - 4 sir.

PPM 1 - 😮

PPM 3 - ABG

PPM 2 - How is she clinically doing now?

PPM 1 - @PPM3 She's sedated fully? With the Progression in  her Renal failure it will become difficult to get the sedatives excreted if when we are planning to wean her.

PPM 3 - We tapered and stopped  sedation today morning sir but she couldn't  tolerate it. So we put her back on sedation. 

PPM 1 - What were the signs of her intolerance?

11-11-2024

PPM 1 - Patient's data at a glance over 4 days since admission.

ABG Values 

PPM 1 - The history is suggestive of sudden stroke and predictably the CT head looks normal. 

12-11-2024

PPM 2 - 😯

PPM 1- Today's update. 

PPM 1 - @PPM4 and PPM5 How many hours since we stopped  her atracurium?

PPM 4 - She expired at 5.09pm sir after she had sudden bradycardia. 

PPM 1 - 🙏 Given mannitol before that?

PPM 4 - Yes sir.