Hemoptysis

40yr old male 



Pt came with C/O blood in cough since 3 days
Pedal edema grade 3 
Breathlessness since 2days 

HOPI:
Patient was apparently assymptomatic 3 days ago and then he noticed blood while coughing, non foul smelling, pink in colour, not associated with clots 8-10 episodes per day. 
He also complained of shortness of breath from 3 days, insidious in onset gradually progressive in nature. Grade3-4
He also complained of pitting type of pedal edema grade 3
No H/o chest pain, tightness.

PAST:
Not a k/c/o DM/HTN/TB/Asthma/Epilepsy 
Operated for thyroid carcinoma 4yrs ago. 
4 years ago in 2018, He noticed a swelling in the neck region, not associated with pain. He was diagnosed with papillary carcinoma of thyroid and had total thyroidectomy done


Drug history: 
On Thyronorm 100 micrograms since 4 years.
No allergic history.
No H/o similar complaints in the past.

PERSONAL:
Appetite- N
Diet- mixed
Bowel and bladder habits- regular 
Sleep - Adequate 
Addictions
He quit smoking and drinking alcohol 10 years ago

FAMILY:
Insignificant

GENERAL EXAMINATION:

Patient is conscious, cohorent, cooperative and well oriented to time, place and person.

Pallor- present


Icterus- absent
Clubbing-absent
Lymphadenopathy- absent
Cyanosis- absent
Pedal edema - present grade 3
 

VITALS: 
B.P: 110/70 mmhg
P.R: 85bpm
R.R: 22 cpm
Temp: 98.3 F
SPO2: 98% on RA

SYSTEMIC EXAMINATION:

Neck: 
In inspection:
Scar on neck for total thyroidectomy present


CVS: S1, S2 heard, no murmurs 

Respiratory system:

Inspection:
No Drooping of shoulder 
No tracheal deviation 
Chest bilaterally symmetrical
Moving equally with respiration on both sides
No dilated veins,pulsations,scars, sinuses.

Palpation:
No tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Vocal fremitus- normal on both sides (equal)
 

Percussion: 


Auscultation: 
decreased breath sounds
Crepts in B/L IAA, ISA (R>L)

CNS: NFND

P/A: Soft, NT

INVESTIGATIONS:

HRCT CHEST:


PROVISIONAL DIAGNOSIS:
Heart failure due to reduced ejection fraction secondary to CAD 
Hemoptysis secondary to pulmonary edema
AKI (pre-renal) with cardiogenic shock 



TREATMENT: 
ICU
Bed 6
Day 2: 21/12/22

Dr. Raveen
Dr. Shashikala
Dr. Prachethan
Dr. Vivek

Pt came with C/O hemoptysis since 3 days
Pedal edema grade 3 
Breathlessness since 2days 

S: 
Pedal edema decreased 
Spasms of upper limb decreased 
No fever spikes
No new complaints

O:
On examination pt is c/c/c
BP: 110/70 mmHg 
PR: 98 bpm
RR: 20 cpm
Temp: 97.8F
SPO2: 90 on RA
CVS: S1, S2 heard, no murmurs 
RS: decreased breath sounds
 Crepts in B/L IAA, ISA (R>L)
CNS: NFND
P/A: Soft, NT

A: Heart failure secondary with reduced EF secondary to CAD
Hemoptysis secondary to ? pulmonary edema
AKI (prerenal)?

P: Inj. Lasix 49mg IV BD
Tab. Aldactone 50mg PO OD
inj. Pan 40mg IV OD 
Inj. Tranexa 500 mg IV BD 
Tab carvedilol 3.125 mg PO OD 
Tab shelcal ct PO OD
Syp. Potchlor 15ml in a glass of water 
Tab. Thyronorm 100mcg po od
Salt restriction <24/day
Water restriction <1.5 lt/day
IVF NS @75ml/hr




AMC Bed 1
UNIT 1
Day 3: at 8:00 AM 

Dr. Raveen
Dr. Venkat Sai 
Dr. Prachethan
Dr. Vivek

Pt came with C/O hemoptysis since 3 days
Pedal edema grade 3 
Breathlessness since 2days 

S: 
Spasms of UL increased
Pedal edema decreased 
No fever spikes
No new complaints

O:
On examination pt is c/c/c
BP: 110/80 mmHg 
PR: 115 bpm
RR: 28 cpm
Temp: 97.8F
SPO2: 90 on 4ltr of O2
CVS: S1, S2 heard, no murmurs 
RS: decreased breath sounds
Crepts in B/L IAA, ISA (R>L)
CNS: NFND
P/A: Soft, NT

A: Heart failure secondary with reduced EF secondary to CAD
Hemoptysis secondary to ? pulmonary edema
AKI (prerenal)?

P: Inj. Lasix 49mg IV BD
Tab. Aldactone 50mg PO OD
Tab Azithromycin 500mg PO OD
inj. Pan 40mg IV OD 
Inj. Tranexa 500 mg IV BD 
Tab carvedilol 3.125 mg PO OD 
Tab shelcal ct PO OD
Syp. Potchlor 15ml in a glass of water 
Tab. Thyronorm 100mcg po od
Salt restriction <24/day
Water restriction <1.5 lt/day
IVF NS @75ml/hr

8:15 AM PT SUDDENLY GOT DESATURATED AND HAD BEEN SHIFTED TO ICU AS HE WAS IN RESPIRATORY DEPRESSION 
As his vitals were dropping (couldn't find pulse,SpO2 -50%), PERFORMED CPR 
INTUBATED AND IS ON VENTILATOR 

Post intubated x-ray: 22/12/22: 

ABG:  after intubation:



Xray on 24/12/22:

Day 5: 24/12/22:
ICU bed 2:



P:
RT feeds WATER 2nd hrly, MILK 4th hrly, with Protein Powder 
FLUID RESTRICTION <1.5lt/day
SALT RESTRACTION <2g/Day
IVF 1NS @ 30ML/HR
INJ. ATRACURIUM @1ml/hr
INJ. MIDAZ @5ML/HR
INJ. NORAD 2amp in 46ML OF NS @8ml/hr, increase or decrease to maintain MAP >65 mmHg 
INJ. DOBUTAMINE amp in 45ml NS at 3.6ml/hr
INJ: TRANEXA 500MG IV/S0S
Inj. LASIX 40MG IV BD 
Inj. PAN 40MG IV OD
Inj. CALCIUM GLUCONATE 200mg IN 100ML NS IV TID OVER 3 HOURS
Inj. AUGMENTIN 1.2 gm IV BD.
Tab. AZITHROMYCIN 500mg RT/OD
T. ALDACTONE 50mg RT/OD
T. CARVEDILOL 3.125 mg RT/OD
T. SHELCAL 600MG RT/TID
T. THYRONORM 150mcg RT/OD
T. BIO-D3 RT/BD (0.28 mcg)
Inj. Neomol 1gm IV SOS 
Syp. Potchlor 15ml RT/BD
Inj. Kcl 2amp in 500ml NS slow over 5hrs.
Change of posture every , suctioning from oral and ET tube 2nd hrly

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