DIAGNOSIS: Acute exacerbation of COPD Type 2 respiratory failure Cor Pulmonale Metabolic acidosis Moderate PAH Urosepsis Hypoxic hepatitis CKD Decubitus ulcer Tinea cruris ADMITTING COMPLAINTS: A 80 years old male arrived in emergency in unconscious state. Patient's party complaints of dyspnoea and tachypnea, drowsiness since morning. History of shortness of breath on exertion for last 2 years. (MMRC-4). Patient was so much breathless that he is unable to carry out his daily activities. No associated chest pain, fever, cough, haemoptysis, weight loss, low appetite, palpitation diaphoresis, snoring, day time sleepiness, Orthopnoea, PND, Apnea, wheeze, vomiting, headache convulsion. Past history of pulmonary Koch's - 60 years back. He is non-smoker and no pet at home. History of bilateral knee joint osteoarthritis and used to take and NSAID regularly. No history of hypertension, Diabetes Mellitus, Thyroid disorder, substance abuse, CAD, COAD, CKD, Rheumatic disease. Patient worked at Hazaribagh Coal mines and had chronic exposure to coal dust for 20 years. Patient is not sensitive to sessional variation cold climate, food etc. ON EXAMINATION: Patient is unconsciousness, patient was intubated and put on ventilator A/C - PRVC mode. Pallor_ Cyanosis - Clubbing - Icterus - Edema + Neck Veins distended Decubitus ulcers grade II over right lateral gluteal region Tinea cruris in gluteal region No neck swelling or lymphadenopathy. BP: 150/80mmHg PR: 108/min Temp: 98°F GCS: E1VTM2 Pupils: Right 3mm and reactive Left 2mm and reactive RR: 40/min SPO2: 47% on room air RBS: 107mg/dl ABG (On admission) - PH -7.012, PC02- 149.8, P02-65.0, Bicarb-31.8, Lactate-4.82. CVS: S1 S2 (+) Chest : Bilateral Basal crept +, Barrel shaped chest CNS: Bilateral planter extensor, Jerks+ P/A: Soft Bowel sound + HOSPITAL COURSE: Patient was admitted with similar complaints in ICU on ventilator (A/C-PRVC mode, Fio2 30%, tidal volume 400 ml, pick pressure 20, Rate 14/min). Routine investigations was advised urgently. Reports arrived showing - Chest X-Ray PA view - Bilateral CP Angle blunted ECG Bifascicular block, T wave inversion in anterior leads, sinus tachycardia. Trop-T Negative. HB-11.4 Raised TLC-19.59, Neutrophil -95.5% Platelet - 1.61 Raised Procalcitonin-0.69 Raised total bilirubin - 3.08 Raised direct bilirubin - 2.28 Raised SGOT-5944 Raised SGPT-3423 Raised ALP-238 Raised NT-pro BNP - 9630 Raised Urea - 98 Raised creatinine -1.24 Low sodium -134 Raised potassium - 5.6 Low calcium -8.3 Raised D-Dimer-7064.27 Raised Urine ACR-600mg albumin / Gram Creatinine. Raised LDH - 915. Raised PT 20 seconds Raised INR 1.75. ALT:LDH- 3.371 suggestive of Hypoxic Hepatitis Anti- HAV and HEV IgM negative HBSAg-Negative, anti HCV- Negative Urine RE - Protein 2 +, Numerous - RBC, Numerous pus cell, bacteria >1000. Blood C/S showing growth of pseudomonas aeruginosa USG whole abdomen mild hepatomegaly, raised cortical echogenicity of both kidney's suggestive of bilateral renal parenchymal disease. 2D Echo - moderate concentric LVH, Dilated RA & RV, LVEF-50-55%, Grade I diastolic dysfunction, mild MR, mild AR, moderate TR (PASP 50mmHg), moderate PAH, dilated IVC (2cm), < 50% inspiratory collapse. Patient was continued on ventilation, Bronchodilators, PPI, subcutaneous anticoagulants, diuretics, antibiotics, steroids, anti-hypertensive and other supportive measures. Patient was extubated after 2 days and was started on NIV (Bipap). Patient was shifted to HDU after 4 days and is being discharged in stable condition.

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any CTPA done to r/o PTE ? @Ashutosh Chandan Dubey

Home BIPAP, OXYGEN and NEBULISATION along with treatment for rest all comorbid conditions to be considered

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