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 This is an online E log to discuss our patient's health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E log also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

A 35 yr old male who is petrol bunk shop worker by occupation came with the chief complaints of Pedal Edema since 7 days , Shortness of breath since 5 days , Abdominal distension since 5 days.

HOPI : 
Patient was apparently asymptomatic 7 days back then developed pedal Edema which is gradual in onset progressively increasing associated with SOB for 5 days initially grade 2 gradually progressed to grade 4 , associated with abdominal distension since 4 days which is gradually increasing day by day and patient came to KIMS for further evaluation.

PAST HISTORY :
-No similar complaints in the past
-Known case of acyanotic congenital heart disease( large sub aorticVSD with left to right shunt).
- VSD patch closure done on 10/01/2001with atrial septostomy done in NIMS on 20/03/2019.
- No history of DM, Hypertension, T.B, Asthma, epilepsy.

PERSONAL HISTORY:
Diet - mixed
Appetite - normal
Bowel and bladder- regular
Sleep - adequate 
Addictions- occasional known alcoholic ( stopped 1 year back)

FAMILY HISTORY:
Not significant.

GENERAL EXAMINATION:
 Conscious, coherent, cooperative 
No pallor, cyanosis, clubbing, Lymphadenopathy. Edema is present.

VITALS:
PR- 100bpm, low volume
RR- 26cpm
B.P - 80/50mm Hg
Afebrile 
Spo2- 78% RA( 10 L of O2- 92%)
JVP raised

SYSTEMIC EXAMINATION:

CVS - S1, S2 heard, pan systolic murmur heard
Respiratory- BAE +, wheeze( end inspiratory) in all areas.
P/A- scaphoid, soft, non tender, distended, BS heard.
CNS- NAD

PROVISIONAL DIAGNOSIS:
 Heart failure???
RHF with severe PAH secondary to chronic PE with known case of large sub aortic VSD with VSD patch closure and atrial septostomy done.

INVESTIGATIONS ORDERED:
CBP, CUE, CXR, ECG, 2D echo
TREATMENT GIVEN:
  1. Inj. NORAD - DS @ 20ml/ hr increased or decreased to maintain MAP at 65 mmHg
  2. Inj. Dobutamine@4ml/hr
  3. Fluid restriction- less than 1L per day
  4. Salt restriction < 2g/ day
  5. Inj. Heparin 5000IU/ IV P/ TID
  6. Inj. Lasix 40 mg in 50 ml NS @ 2 ml/ hr
  7. Spy. Lactulose5 ml / PO/ night if stool not passed.
  8. Tab. Udiliv 300 mg/ PO/ BD.
  9. Propped up position
  10. Oxygenation to maintain Spo2 > 90 %
  11. Intermittent BIPAP.
  12. Inj Pan 40 mg/ IU/ OD.
  13. Inj. Levofloxacin 500 mg/ IV / OD
  14. Inj. Piptaz 2.25 g/ IV/ TID
CPR notes on 3/5/2021:
 4:50 pm: 
PR - NR
BP - NR
SPO2 -35%
CPR initiated
Inj. Adrenaline 1 mg IV was given.

4:55 pm:
PR- NR
BP - NR
SPO2- NR
CPR continued, 
Inj. Adrenaline 1mg IV was given

5:00pm
PR- NR
BP - NR
SPO2- NR
CPR continued, 
Inj. Adrenaline 1mg IV was given

5:05 pm 
PR- NR
BP - NR
SPO2- NR
CPR continued, 
Inj. Adrenaline 1mg IV was given

5:10 pm
PR- NR
BP - NR
SPO2- NR
CPR continued, 
Inj. Adrenaline 1mg IV was given

5:15 pm
PR- NR
BP - NR
SPO2- NR
CPR continued, 
Inj. Adrenaline 1mg IV was given

5:20 pm
PR- NR
BP - NR
SPO2- NR
Inj. Adrenaline 1mg IV was given

Inspite of all the efforts patient couldn’t be revived and declared dead at 5:20 pm on 3-05-2021 with ECG showing No Electrical Activity.
Immediate cause of Death : Sudden CardioPulmonary Arrest
Antecedent cause of Death : Right Heart Failure with severe PAH with AKI with Pneumonia with Cardiogenic Shock


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