Case 5. 55 M with SOB,Decreased UO since 20 days

DOA 7/9/24

Expired on 8/9/24

Diagnosis

SEVERE METABOLIC ACIDOSIS

REFRACTORY HYPOTENSION

TYPE 1 RESPIRATORY FAILURE

PULMONNARY OEDEMA WITH HFREF

UREMIA WITH MYOCLONIC JERKS,

AZOTEMIA WITH CHRONIC KIDNEY DISEASE

K/C/O DM II SINCE 10 YEARS

Case History and Clinical Findings

C/O SHORTNESS OF BREATH SINCE 20 DAYS

C/O DECREASED URINE OUTPUT SINCE 20 DAYS

C/O DECREASED APPETITE SINCE 20 DAYS

HOPI:

PATIENT WAS APPARENTLY ALRIGHT 20 DAYS AGO WHEN HE DEVELOPED SHORTNESS OF

BREATH WHICH WAS INSIDIOUS IN ONSET , GRADUALLY PROGRESSIVE IN NATURE ,

INITIALLY IT WAS ON LESS THAN ORDINARY ACTIVITY , SINCE YESTERDAY IT

PROGRESSED EVEN ON REST ASSOCIATED WITH ORTHOPNEA AND PND.H/O SIMILAR

COMPLAINTS ON AND OFF SINCE 2YRS

PATIENT ALSO COMPLAINTS OF DECREASED URINE OUTPUT AND APPETITE SINCE 20

DAYS. B/L PEDAL EDEMA PITING TYPE UPTO KNEES SINCE 20 DAYS. PATIENT IS K/C/O CKD

, WAS ON MAINTAINENCE HEMODIALYSIS 2YEARS AGO , HE DISCONTINUED DIALYSIS

SINCE THEN AND WAS NOT COMPLIANT TO TREATMENT.

PAST HISTORY:

K/C/O DM II SINCE 10 YEARS

K/C/O Htn SINCE 3 YEARS

CKD SINCE 2 YEARS

PATIENT WAS ON CKD ON MHD

LAST DIALYSIS 2022

N/K/C/O HTN,CAD,ASTHMA,TB

PERSONAL HISTORY

APPETITE - NORMAL

DIET - MIXED

BOWEL - REGULAR

BLADDER - DECREASED URINE OUTPUT

NO KNOWN ALLERGIES

ADDICTIONS-OCCASSIONL ALCOHOLIC AND SMOKER , STOPPED SINCE 2 YEARS

GENERAL EXAMINATION :

PATIENT IS NOT ORIENTED TO TIME , PLACE AND PERSON

NO SIGNS OF PALLOR,ICTERUS,CYNOSIS,CLUBBING,LYMPHADENOPATHY,

TEMP: 98.5F

BP:90/50 MMHG

RR: 38 CPM

PR:132 BPM

SPO2 77% AT RA

GRBS:245 MG/DL

FBS 124 mg/dl

PLBS 245 mg/dl

Hba1c -6.6 %

SYSTEMIC EXAMINATION:

CVS: S1S2 HEARD. NO MURMURS.

RS: BAE+.B/L DIFFUSE CREPTS +

P/A: SOFT,NON-TENDER.

CNS: NFND

Investigation

BLOOD GROUPING AND RH TYPING (7/9/24): A POSITIVE

SEROLOGY ON 7/9/24

HIV 1/2 RAPID TEST: NON REACTIVE

HBsAG RAPID: NEGATIVE

ANTI HCV ANTIBODIES RAPID: NON REACTIVE

HEMOGRAM ON 7/9/24

HB : 11.7

TOTAL COUNTS :41200

PCV : 32.5

PLATELET COUNT 2.94

IMPRESSION :NORMOCYTIC NORMOPCHROMIC BLOOD PICTURE WITH NEUTROPHILIC

LEUKOCYTOSIS

HEMOGRAM ON 8/9/24

HB :11.6

TOTAL COUNTS :23800

PCV :33.4

PLATELET COUNT : 2.4

IMPRESSION :NORMOCYTIC NORMOCHROMIC BLOOD PICTURE WITH NEUTROPHILIC

LEUKOCYTOSIS

BLOOD LACTATE ON 8/9/24: 25mg/dl

ABG ON 8/9/24

PH: 7.16

PCO2: 28.3

PO2: 81.0

HCO3-: 9.7

SO2: 90.8

RFT ON 8/9/24

UREA: 354

CREATININE : 9.1

PHOSPHOROUS : 8.7

SODIUM: 119

POTASSIUM: 4.8

CHLORIDE: 89

ABG (2ND) ON 8/9/24

PH:7.245,

PCO2:23.6mmHg,

PO2 : 55.2,

SO2 :82.1,

HCO3-:9.8mmol/L

ULTRA SOUND ON 7/9/24

RT KIDNEY: 8.9X4.4 cm

LT KIDNEY 9.2X4.2 cm

IMPRESSION: B/L KIDNEYS SHOWS GRADE III RPD CHANGES

Treatment Given(Enter only Generic Name)

1)INTERMITTANT SUPPORT

2)O2 SUPPLEMENTATION TO MAINTAIN SPO2 98%

3)INJ.PIPTAZ 2.5MG IV TID

4)INJ.METROGYL 500 MG IV TID

5)INJ.NORADRENALINE 2 AMPOULES IN 46ML NS @18ML/HR TO MAINTAIN MAP >65MM HG

6)INJ.VASOPRESSIN 2 AMP IN 48ML NS IV @1.2 ML/HR TO MAINTAIN MAP >65MMHG

7)T.NODOSIS 500MG PO BD

8)INJ EPO 4000 IU ONCE WEEKLY SC

9)INJ.LASIX 40MG IV BD IF SBP >110 MMHG

10)T SHELCAL CT PO OD

11)INJ HAI SC TID IF PRE MEAL GRBS>100MG/DL

12)MONITOR VITALS HOURLY AND INFORM SOS

13) INJ DOBUTAMINE 5M IN 45 ML NS IV/@3ml/hr

EXPIRED DUE TO SEVERE METABOLIC ACIDOSIS WITH REFRACTORY

HYPOTENSION WITH TYPE I RESPIRATORY FAILURE WITH PULMONARY OEDEMA WITH HFREF

@⁨Meta AI⁩ Coding: identify initial codes and labels to capture the key concepts and ideas.

Categorization: group the codes into categories and subcategories to organize the data.

Theme identification: identify the emerging themes and patterns in the data.

Theme representation: present the themes as learning points, highlighting the key findings and insights related to To estimate the variability in Clinical, Radiological and Laboratory, therapeutic factors in this patient of diabetes with multimorbidities presenting to medicine department and assess factors influencing the outcome and what could be the possible intervention to prevent the death in this patient

Analyse each and every parameter provided And @⁨Meta AI⁩ let us know new insights about the topic and case rather than what we already know

meta AI reply

*Coding*

Initial codes based on key concepts and ideas:

1. Multimorbidity (Diabetes, CKD, Hypertension)

2. Severe Metabolic Acidosis

3. Refractory Hypotension

4. Type 1 Respiratory Failure

5. Pulmonary Edema

6. Heart Failure with Reduced Ejection Fraction (HFrEF)

7. Uremia with Myoclonic Jerks

8. Azotemia with Chronic Kidney Disease

*Categorization*

*Categories and Subcategories:*

1. *Patient Profile*

- Diabetes Mellitus Type 2 (10 years)

- CKD (2 years)

- Hypertension (3 years)

- Non-compliance to dialysis and treatment

2. *Clinical Presentations*

- Shortness of breath

- Decreased urine output

- Decreased appetite

- Bilateral pedal edema

3. *Laboratory Findings*

- Severe metabolic acidosis (ABG pH 7.16, HCO3- 9.7)

- Elevated urea and creatinine levels

- Electrolyte imbalance (sodium 119, potassium 4.8)

- High lactate levels (25 mg/dl)

4. *Therapeutic Interventions*

- Oxygen supplementation

- Vasopressors (norepinephrine, vasopressin)

- Antibiotics (Piptaz)

- Metronidazole

- Sodium bicarbonate (T. Nodosis)

5. *Outcome*

- Patient expired due to severe metabolic acidosis with refractory hypotension and type 1 respiratory failure

*Theme Identification*

Emerging themes and patterns:

1. *Complexity of Multimorbidity Management*: The case highlights the challenges in managing patients with multiple chronic conditions, requiring a comprehensive and integrated approach.

2. *Importance of Timely Intervention*: The patient's severe metabolic acidosis and refractory hypotension suggest that timely intervention is critical in preventing adverse outcomes.

3. *Impact of Non-compliance*: The patient's non-compliance to dialysis and treatment likely contributed to the development of severe complications.

*Theme Representation*

*Learning Points:*

1. *Early Recognition and Management*: Early recognition and management of complications in patients with multimorbidities can improve outcomes.

2. *Importance of Compliance*: Ensuring patient compliance to treatment plans is crucial in preventing adverse outcomes.

3. *Multidisciplinary Approach*: A multidisciplinary approach involving various specialties can improve patient outcomes.

*Possible Interventions to Prevent Death:*

1. *Timely Initiation of Dialysis*: Initiating dialysis earlier in the patient's treatment course may have prevented the development of severe metabolic acidosis and uremia.

2. *Aggressive Management of Metabolic Acidosis*: More aggressive management of metabolic acidosis, including the use of bicarbonate therapy or other interventions, may have improved the patient's outcome.

3. *Optimization of Vasopressor Therapy*: Optimization of vasopressor therapy, including the use of alternative agents or dosing strategies, may have improved the patient's blood pressure and perfusion.

*New Insights:*

1. *The importance of addressing non-compliance*: The case highlights the importance of addressing non-compliance to treatment plans in patients with chronic conditions.

2. *The need for timely intervention*: The case emphasizes the need for timely intervention in patients with severe metabolic acidosis and refractory hypotension.

3. *The complexity of managing multimorbidity*: The case illustrates the complexity of managing patients with multiple chronic conditions and the need for a comprehensive and integrated approach.