4. HISTORY OF PRESENTING ILLNESS:
• According to the statement of the patient’s son patient was relatively well 1day back, since then
patient develops pain in the right side of the lowed abdomen . Pain was intermittent, sharp, and
radiating to the back. Pain was associated with anorexia and nausea but not associated with
vomiting or diarrhea. For last 4 hours patient develops sudden respiratory distress which was
progressively increasing . There was no history of fever ,chest pain, hemoptysis, cough or swelling in
5. HISTORY OF PAST ILLNESS:
Patient had H/O Covid-19 Pneumonitis last year & was admitted in to ICU of CMCH
She had H/O Acoustic Neuroma (operated) on 1999
H/O CVD followed by VP shunt on 2000.
Patient is Diabetic and Hypertensive for 6 years,
Asthmatic for 3 years
H/O HIP prosthesis surgery for two time in the year of 2000 and 2005
OSA /Pickwickian Syndrome
8. GENERAL EXAMINATION
• Patient was dyspneic and anxious looking
• Morbid obesity
• Decubitus was on her choice
• No Anemia, Jaundice,Cyansis,edema,clubbing,Koilonychea or leukonykia was present
• BP-140/90 mm of hg
• Respiratory Rate- 24 b/m
9. GENERAL EXAMINATIONS:
PBW.: 110 KG BP:140/90 mm HR: 78 B/min.
Temp.: 98 Normal
LlEUKONYCHEA were Absent
• Pupil – Normal reacting to light
• M/P – 3/5 in all 4 limbs.
• Neck rigidity – absent
• Planter- equivocal (B/L)
HR-78b/m , Rhythm was sinus
No murmur or added sound was
11. RESPIRATORY SYSTEM:
• Breath Sound was VESICULAR type bilaterraly
• Fine crepes was present on both lung field
• Abdomen was soft ,nontender
• Bowel Sound was present,
• no palpable organomegaly found
• Foley Catheter was done in ER
>Other systems reveals no significant findings.
22. THROAT SWAB C/S- ACINETOBACTER BAUMANNII
URINE C/S – NO GROWTH FOUND
BLOOD C/S –NO GROWTH FOUND
23. ULTRASONOGRAM OF WHOLE ABDOMEN
• Mild fatty changes in liver and hepatic calcification in right lobe.
• Bilateral renal parenchymal changes.
24. RIGHT LOWER EXTREMITY ARTERIES COLOUR DOPPLER
• Mild diffuse atherosclerotic changes involving right lower extremity arteries.
• Normal good triphasic flow pattern in right lower limb arteries.
25. LEFT LOWER EXTREMITY ARTERIES COLOUR
• Mild diffuse atherosclerotic changes involving left lower extremity arteries.
• Normal good triphasic flow pattern in left lower limb arteries.
26. LEFT LOWER LIMB VENOUS COLOUR DOPPLER STUDY
No Doppler evidence of deep vein thrombosis in left lower limb
27. RIGHT LOWER LIMB VENOUS DOPPLER
No Doppler evidence of deep vein thrombosis in right lower limb.
As per Clinical and Rediological and lab findings the following mentioned treatment was given
• 1.Stat LMWH (60 unit 12 hourly)
• 2.Epmperical antibiotic therapy
• 3. Regula Antihypertensive Medication
• 4. Regular Lipid lowering agent
• 5.Regular antidiabetic Medication
• 6.Nebuligation with bronchodilators and Steroid
• 7.Mechanical DVD pump
• Additional Mx- Regular chest and limb physiotherapy , Nutritional support along with Proper
29. CASE SUMMARY
Mrs Kamrunessa, 79-year female came to our ER on 02July’Morning @ 8:40AM with the complains of pain in the abdomen located right side, for last
one day; her pain was sharp in nature & radiate to the back & it’s not associated with vomiting & alter bowel movement but associated with
Anorexia. But she developed resp. distress last 4 hours, for that reason her attendant admitted her in the EHC.
She had h/o Covid-19 Pneumonitis last year & admitted in to CMCH ICU. There she had h/o Per Rectal bleeding & dx for 2˚ Hemorrhoid.
She had h/o Acoustic Neuroma (operated) on 1999 & h/o CVD followed by VP shunt on 2000. She had also h/o Hip Prosthesis two times at year of
2000 & 2005. She was hypertensive & diabetic for last 6 years on medication. She was on medication for Asthma for last 2-3 year.
After admission in the EHC, initially primary assessment done at ER; after that she shifted to the yellow zone. As Rt-PCR came (-)ve, so pt shifted to
the MICU for further management. During admission pt was semiconscious & drowsy, GCS: E2+V3+M5=10/15; BP: 150/100 mmHg; SpO2: 98% with
O2 5l/min & pt was afebrile.
In MICU secondary review had done & Internist & Pulmonologist visited the pt & they suspected Pulmonary Embolism as Well’s Score: 4.5
(moderate risk); Revised Geneva Score: 4 (moderate risk) & 2 Criteria meet in PERC rule. So immediate Brain CT excluded & Pulmonary CT
Angiogram had done which reveals Right middle lobe Arterial embolism. So LMWH was started immediately. As patient had T2 Respiratory failure
with Resp. acidosis so NIV had started. In next day morning a combined medical board had arranged regarding the review treatment options, which
consists: Internist/Intensivist; Neurosurgeon; Cardiologist; Cardio-vascular surgeon; Pulmonologist & Orthopedic consultant. The medical board
advice the continue the present treatment & checkout the other etiology. After finishing the 10 doses of LMWH, oral anticoagulant had started. In
while patient need NIV(Bipap); which switch to CPAP later on.
30. MEDICAL BOARD OPINION
A medical board was held on 3/7/2021at 3.30pm consisting consultant of Critical care medicine, ,Internal Medicine ,
Respiratory Medicine, Cardiology , Vascular surgery and General surgery
Dx- Type-II Respiratory Failure due to Acutee pulmonary Embolism with OHS due to morbid obesity with DM with
H/O V-P shunt , 2* Hemorrhoid and U-V prolapsed
Medical board decision :
1.Target INR-2 to 2.5
2.Routine check- PT, APTT, CBC, Electrolyte, Creatinine, CxR, ECG
3.ABG 4 hourly
4.BiPAP-1st day 24 hour,2nd day 18 hours then according to patient requirement
5.Stop DVD pump
6.Antibiotic changed to Ertapenem from Fimoxyclav
7.I/V Fluid : H/S- 1500ml + N/S 500 ml daily
31. TOTAL HOSPITAL COURSE
Patient was admitted in ER on 02.07.2021 @ 8.40 am
Patient was shifted to Yellow Zone on 02.07.2021 @ 8.53am
Patient was shifted to HDU , After RT-PCR comes negative on 02.07.2021 @ 4.00pm
Patent was Step downed to Cabin on 8.07.2021 @ 1.00 pm
Patient was discharged from the Hospital on firstname.lastname@example.org
• Patient was discharged form the hospital on 10.07.2021 @ 12.40pm
• During Discharge patient condition was improved and cured