PaJR Case Reports: 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.