73 yr old male patient with myxedema Coma.

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

A 73 y/o male came to the casuality in unconscious state since 12 pm yesterday.

#HISTORY OF PRESENTING ILLNESS:-
The patient was apparently asymptomatic 3 days back. Then he had fall from bed, sustained injury over chest region. Went to local doctor and got treated (his bp there was 160/90 mmHg) with
1. Inj Mannitol 100mg IV stat
2. Tab Taxim 
3. Inj Decadron
4. Inj Hydrocortisone
5. Inj Lasix
The patient was c/c/c till yesterday morning. Then he went to the same doctor for follow up. Patiemt has not been responding to commands since 9 am. He became completely unconscious since 12
 noon.
#PAST HISTORY:-
Not a k/c/o DM, HTN, TB, asthma, epilepsy.

#PERSONAL HISTORY:-
Diet - Mixed
Appatite - Reduced since 10 days
Sleep - Adequate
Bowel and bladder - Disturbed
Addictions - Regular alcoholic 

#FAMILY HISTORY:-
None significant 

#GENERAL EXAMINATION:-
Pt is unconscious
Moderately built and nourished
Afebrile
No icterus, cyanosis, lymphadenopathy, clubbing, lower limb pitting edema. Hyper pigmented patches seen on chest.

BP 120/70 mmHg
PR 72 bpm
RR 9 cpm
SpO2 97% in room air
GRBS 80mg/dl

#SYSTEMIC EXAMINATION:-

*CVS:-
S1 S2 heard
No thrills and murmurs

*RS:-
Dyspnoea -
Wheeze -
Trachea central
Breath sounds vesicular

P/A
Soft, non-tender, bowel sounds +

*CNS:-
Pt is unconscious
No signs of neck stiffness
Power cannot be elicited
Hypertonia in all 4 limbs
Pupils sluggishly reacting to light
GCS 3/15
Reflexes          R           L
1. Biceps         -           -
2. Triceps        -          -
3. Supinator    -           -
4. Knee             -           -
5. Ankle             -           -
6. Plantar       mute      mute
#Investigations:-
*ABG:-
pH 7.5
pCO2 32.7
pO2 67.1
HCO3 29.8

Serology negative
*CBP:-
Hb -10.6
TLC -8400
RBC -3.8mill
PLT -1.85lakh
N,L,M,E,B 80,10,6,3,1
*SERUM ELECTROLYTES:-
Na -128
K -4
Cl -90
Ca -9.2
Urea -32
Cr -1.3
#PROVISIONAL DIAGNOSIS:-
Altered sensorium under evaluation.
*X-RAY :-
*ECG:-
SOAP NOTES DAY 1
ICU BED 1
GENERAL EXAMINATION:-
S
Pt  E2V4M2
O
Pallor -
Icterus -
Cyanosis +
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 80/50 mmHg
RR 10cpm
SpO2 98% at room air
PR central pulse +
GRBS 102mg/dl
I/O 4000/2980
Pupils sluggish, reactive to light
SYSTEMIC EXAMINATION:-
CVS S1 S2 +
RS B/L crepts +
P/A soft, non tender
Motor 
Tone reeuced in all 4 limbs
Reflexes          R           L
1. Biceps         +           +
2. Triceps         +         +
3. Supinator     -           -
4. Knee             +          +
5. Ankle            +          +
6. Plantar       mute      mute
#INVESTIGATIONS:-
ESR -40mm
PT -15 sec
INR -1.11
APTT -31 sec
Na -124meq
K -3.4meq
Cl- 90meq
*Thyroid Profile:-
T3- <0.1ng/dl
T4 -0.2ng/dl
TSH -71.35
#ECG:-
2D ECHO:-
#PROVISIONAL DIAGNOSIS:-
ALTERED SENSORIUM SECONDARY TO MYXEDEMA COMA WITH 1ST DEGREE HEART BLOCK

#TREATMENT:-
1. IVF NS, RL at 150ml/hr
2. O2 inhalation
3. Ryles tube feeds 100ml water (4th hrly), 200ml milk with protein powder (4th hrly)
4. 8nj OPTINEURON 1amp in 100ml NS slow iv od
5. Head end elevation
6. Inj NA 2 amp in 46ml NS iv at 24ml/hr (to maintain MAP 55-65 mmHg)
7. Inj DOBUTAMINE 1 amp in 45ml NS at 20ml/hr
8. Tab LEVOTHYROXINE 100mcg
9. Nebulisation with BUDECORT and DUOLIN 6th hrly
10. Syp POTCHLOR 15ml in a glass of water/RT tid
11. Monitor vitals 2bd hrly
12. I/O charting

#Emergency pericardiocentesis done in view of refractory hypotension secondary to pericardial tamponade in MYXEDEMA crisis Patient..



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