47 yr old male came to casualty with c/o SOB , cough with sputum since 4days .


HOPI-
Pt was apparently asymptomatic 15yrs back had intermittent SOB (grade 2) assoc. with cough with sputum (?asthma ) for which pt was on intermittent inhalers .

3yrs back had H/o pedal oedema , SOB (grade-4) with orthopnea , abdominal distension , consulted the cardiologist , said to have CAD , patient was on TAB.frusemide , TAB PAH(20 mg) , Echo shows : RA , RV dilated with EF 50%.Patient was on irregular medication for CAD and Right heart failure with PAH.

4days back had H/o pedal oedema , abdominal distension, SOB(grade-4), decreased response , not responding to deep stimuli . Admitted in outside hospital with SpO2 :80 @ RA, RR:38/min . Patient was put on Inj.NA & dobutamine , O2 inhalation & intermittent BiPAP , Inj. Zostrutum, Inj thiamine  

Past History :
Not a k/c/o HTN,DM,TB, Asthma, CAD, CVD

Personal history :
Diet-mixed 
Appetite - normal 
B&B - regular 

Family  history -not significant

On Examination :
Patient is 
Afebrile 
BP- 90/60 mmHg
PR- 87bpm
SpO2-93%@RA




Systemic examination :
CVS - S1  S2 +  , No murmurs 
RS- B/L crrpts + in IAA ,IMA ,ISA
P/A - soft , non tender , BS +
CNS - NAD

Provisional diagnosis:
Right heart failure with CAD with denovo DM type 2

Investigations :











8/12/21



9/12/21




10/12/21


11/12/21







12/12/21
12AM
4:30 AM

8PM
11PM

13/12/21

2AM

   6:30AM







14/12/21

3AM


6AM


11AM

3pm
8pm

15/12/21

12:30 AM

6AM

11AM

3PM





Treatment history: 
1.Head end elevation 
2.O2 inhalation to maintain SpO2
3.Inj. Lasix 40mg IV/BD (if SBP
4.Inj. pantop 40mg IV /BD
5.Nebulisation with budecort -12th hrly , duolin -8th hrly .
6.Tab. metformin 500mg PO / BD 
7. I/O , temp monitoring 
8. Weight monitoring - daily 

SOAP notes :
DAY1
S- sob decreased 
Cough with sputum +
No fever spikes
Passed stools yesterday

O- pt is conscious,coherent 
Afebrile
PR 94/min
Bp 110/80 mmhg
RR 22 cpm
Spo2 96%
Cvs s1s2 +
Rs b/l air entry+,b/l basal crepts +
P/a soft, non tender
Grbs 174 mg/dl
I/o 1000/2000

pH -7.35----7.38----7.41----7.38
Pco2-131--110----117-----137
Po2---340---68.6--62.1---83.6
Hco3--70.5--64.4--74---80.2
St.hco3--61.9--56--66.2--72.3
O2 sat--99.4---92--90---95.2

A- Corpulmonale with type 3 pulmonary arterial hypertension 
Severe respiratory acidosis
bronchial asthma
Denovo diabetes 

P- NIV with bipap continously
Neb with duolin ,mucomist tid,Budecort bd
Chest physiotherapy
Inj Augmentin 1.2 g iv bd
Inj hai s/c tid according to grbs
Monitor vitals
http://snehakalyankar.blogspot.com/2021/12/right-heart-failure-with-cad-with.html

DAY2
S- sob decreased 
Cough with sputum +
No fever spikes
Not Passed stools 

O- pt is conscious,coherent 
Afebrile
PR 96/min
Bp 130/80 mmhg
RR 20 cpm
Spo2 96%
Cvs s1s2 +
Rs b/l decreased breath sounds+
P/a soft, non tender
Grbs 101 mg/dl
I/o 800/1000

pH -7.35----7.38----7.41----7.38
Pco2-131--110----117-----137
Po2---340---68.6--62.1---83.6
Hco3--70.5--64.4--74---80.2
St.hco3--61.9--56--66.2--72.3
O2 sat--99.4---92--90---95.2

A- Corpulmonale with type 3 pulmonary arterial hypertension 
Severe respiratory acidosis
bronchial asthma
Denovo diabetes 

P- NIV with bipap continously
Neb with duolin ,mucomist tid,Budecort bd
Chest physiotherapy
Inj Augmentin 1.2 g iv bd
Inj hai s/c tid according to grbs
Monitor vitals

Day 3

S- pt on mechanical ventilator day 2
No fever spikes
Not Passed stools 

O- pt on mechanical ventilator
ACMV VC mode
Rr-15
Vt-400
Peep-8
Fio2-40%
On inj vecuronium 1mg/ml/hr,midazolam 30mg/hr infusion 
Afebrile
PR 96/min
Bp 120/80 mmhg 
RR 20 cpm
Spo2 96%
Cvs s1s2 +
Rs b/l decreased breath sounds+
P/a soft, non tender
Grbs 205 mg/dl
I/o 1300/700

A- Corpulmonale with type 3 pulmonary arterial hypertension 
With type 2 respiratory failure
Severe respiratory acidosis
With ?copd
Denovo diabetes 

P- Neb with duolin ,mucomist tid,Budecort bd
Frequent Et and oral suction 
Chest physiotherapy
Inj Augmentin 1.2 g iv bd
Inj hai s/c tid according to grbs
Rt feeds 4th hrly
Monitor vitals
I/o charting

Day 4

S- pt on mechanical ventilator day 3
No fever spikes


O- pt on mechanical ventilator
ACMV VC mode
Rr-15
Vt-400
Peep-5
Fio2-70%
On inj vecuronium 4mg/hr,midazolam 10mg/hr and fentnyl 6 ml/hr infusion 
Afebrile
PR 94/min
Bp 90/60 mmhg 
RR 15 cpm
Spo2 96%
Cvs s1s2 +
Rs b/l air entry +
P/a soft, non tender
Grbs 146 mg/dl
I/o 3000/2500

A- Corpulmonale with type 3 pulmonary arterial hypertension 
With type 2 respiratory failure
Severe respiratory acidosis
With ?copd
Denovo diabetes 

P- Neb with duolin ,mucomist tid,Budecort bd
Frequent Et and oral suction 
Chest physiotherapy
Inj Augmentin 1.2 g iv bd
Inj hai s/c tid according to grbs
Rt feeds 4th hrly
Monitor vitals
I/o charting


Day 5
S- pt on mechanical ventilator day 4
fever spikes + yesterday 


O- pt on mechanical ventilator
ACMV VC mode
Rr-18
Vt-400
Peep-5
Fio2-70%
On inj vecuronium 4mg/hr,midazolam 2mg/hr and fentnyl 2 ml/hr infusion 
Afebrile
PR 92/min
Bp 100/60 mmhg 
RR 18 cpm
Spo2 96%
Cvs s1s2 +
Rs b/l air entry +,b/l basal crepts+
P/a soft, non tender
Grade 1 bed sore +
Grbs 286 mg/dl
I/o 1700/900

A- Corpulmonale with type 3 pulmonary arterial hypertension 
With type 2 respiratory failure
Severe respiratory acidosis
With ?copd
Denovo diabetes with grade 1 bed sore

P- Neb with duolin ,mucomist tid,Budecort bd
Frequent Et and oral suction 
Chest physiotherapy
Frequent change of position
Inj meropenem 1 g iv bd
Inj hai s/c tid according to grbs
Rt feeds 4th hrly
Monitor vitals
I/o charting


Day 6
S- pt on mechanical ventilator day 5
fever spikes + yesterday 


O- pt on mechanical ventilator
ACMV VC mode
Rr-20
Vt-360
Peep-4
Fio2-60%
On inj vecuronium 4mg/hr,midazolam 2mg/hr and fentnyl 10 ml/hr infusion 
Afebrile
PR 88/min
Bp 90/60 mmhg 
RR 20 cpm
Spo2 96%
Cvs s1s2 +
Rs b/l air entry +, crepts+ in b/l basal ,rt infraclavicular areas
P/a soft, non tender
Grade 1 bed sore +
Grbs 296 mg/dl
I/o 2400/3000

A- Corpulmonale with type 3 pulmonary arterial hypertension 
With type 2 respiratory failure
Severe respiratory acidosis
With ?copd
Denovo diabetes with grade 1 bed sore

P- Neb with duolin ,mucomist tid,Budecort bd
Frequent Et and oral suction 
Chest physiotherapy
Frequent change of position
Inj meropenem 1 g iv bd
Inj hai s/c tid according to grbs
Rt feeds 4th hrly
Monitor vitals
I/o charting


Day 7
S- pt on mechanical ventilator day 6
fever spikes + 

O- pt on mechanical ventilator
ACMV VC mode
Rr-20
Vt-360
Peep-5
Fio2-70%
On inj vecuronium 4mg/hr,midazolam 6mg/hr and fentanyl 15 ml/hr infusion 
Afebrile
PR 86/min
Bp 140/80 mmhg 
RR 20 cpm
Spo2 97%
Cvs s1s2 +
Rs b/l air entry +, crepts+ in b/l basal ,rt infraclavicular areas
P/a soft, non tender
Grade 1 bed sore +
Grbs 231 mg/dl
I/o 3500/1950

A- Corpulmonale with type 3 pulmonary arterial hypertension 
With type 2 respiratory failure
Severe respiratory acidosis
With ?copd
Denovo diabetes with grade 1 bed sore

P- Neb with duolin ,mucomist tid,Budecort bd
Frequent Et and oral suction 
Chest physiotherapy
Frequent change of position
Inj meropenem 1 g iv bd
Inj hai s/c tid according to grbs
Rt feeds 4th hrly
Monitor vitals
I/o charting


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