Case 3 .68 F with sob,decreased UO

DOA- 21/2/24

DOD-27/2/24

Diagnosis

COMMUNITY ACQUIRED PNEUMONIA / UTI

SEVERE SEPSIS WITH MODS ( AKI / ALI ) - RESOLVING

ATRIAL FIBRILLATION ( PAROXYSMAL ) SECONDARY TO CAD

AKI ON CKD ( STAGE 5 ) - 4 SESSIONS OF HD

HEART FAILURE WITH MID RANGE EJECTION FRACTION ( EF = 45 % ) SECONDARY TO CAD (

RCA HYPOKINESIA )

K/C/O TYPE 2 DIABETES MELLITUS SINCE 20 YRS

K/C/O HTN SINCE 20 YRS

K/C/O HYPOTHYROIDISM SINCE 15 YRS

K/C/O CAD SINCE 7 YRS - S/P : PTCA

Case History and Clinical Findings

C/O :

PT CAME WITH C/O SOB SINCE 3 DAYS

C/O DECREASED URINE OUTPUT SINCE 2 DAYS

HOPI :

PT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK THEN SHE DEVELOPED SOB ,

INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE GRADE 3 H/O DECREASED URINE

OUTPUT NOT A/W BURNING MICTURITION

NO H/O VOMITINGS , DIARRHOEA, CHEST PAIN , SEIZURES, ALTERED SENSORIUM

PAST HISTORY

K/C/O T2 DM SINCE 2O YEARS ON 18 U - 0 - 15 U MIXTARD

K/C/O HTN SINCE 20 YEARS ON T. AMLONG 5MG OD

K/C/O CKD SINCE 15 YEARS ON CONSERVATIVE MANAGEMENT

H/O CAD 15 YEARS BACK

K/C/O HYPOTHYROIDISM SINCE 15 YEARS ON 150 MG LEVOTHYROXINE

O/E :

PT IS C/C/C

TEMP : 98.3 F

PR : 90 BPM

RR : 24 CYCLE S/MIN

BP : 100/60 MMHG

SPO2 : 96 % @ RA

GRBS : 315 MG %

SYSTEMIC EXAMINATION :

CVS : S1 AND S2 + LOUD P2 +

RS : B/L AIR ENTRY +

COARSE CREPTS AT RT ISA,AA,IAA

P/A : SOFT, NON TENDER

CNS : NFND

CARDIOLGY REFERRAL DONE ON 24/2/24 I/V/O ATRIAL FIBRILLATION AND DOSAGE

MODIFICATION

ADVISED - CONTINUE TREATMENT

MAINTAIN INPUT / OUTPUT CHARTING WITH NEGATIVE BALANCE

CONTINUE TAB CARDARONE 100 MG OD, TAB CARVEDILOL 3.125 MG OD

1 UNIT PRBC TRANSFUSION DONE ON 26/02/2024

Investigation

NameValueNameValueRFT 21-02-2024 02:18:PM UREA171 mg/dlCREATININE5.3 mg/dlURIC

ACID8.6 mg/dlCALCIUM9.8 mg/dlPHOSPHOROUS6.1 mg/dlSODIUM131 mEq/LPOTASSIUM4.0

mEq/LCHLORIDE99 mEq/LABG 21-02-2024 02:18:PM

PH7.14PCO241.5PO2125HCO313.7St.HCO313.5BEB-14.1BEecf-13.6TCO230.4O2 Sat95.4O2

Count12.9LIVER FUNCTION TEST (LFT) 21-02-2024 02:18:PM Total Bilurubin2.43 mg/dlDirect

Bilurubin1.23 mg/dlSGOT(AST)18 IU/LSGPT(ALT)24 IU/LALKALINE PHOSPHATASE363

IU/LTOTAL PROTEINS5.6 gm/dlALBUMIN2.8 gm/dlA/G RATIO0.97COMPLETE URINE

EXAMINATION (CUE) 21-02-2024 02:18:PM COLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+++SUGARNilBILE

SALTSNilBILE PIGMENTSNilPUS CELLS4-5EPITHELIAL CELLS2-3RED BLOOD CELLS4-

5CRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilHBsAg-RAPID21-02-2024

02:18:PMNegative Anti HCV Antibodies - RAPID21-02-2024 02:18:PMNon Reactive BLOOD

UREA22-02-2024 01:17:AM124 mg/dlPOST LUNCH BLOOD SUGAR22-02-2024 01:17:AM376

mg/dlSERUM CREATININE22-02-2024 01:17:AM4.1 mg/dlSERUM ELECTROLYTES (Na, K, C l) 22-

02-2024 01:17:AM SODIUM137 mEq/LPOTASSIUM4.3 mEq/LCHLORIDE102 mEq/LRFT 22-02-

2024 02:28:PM UREA79 mg/dlCREATININE2.7 mg/dlURIC ACID3.9 mg/dlCALCIUM9.5

mg/dlPHOSPHOROUS3.5 mg/dlSODIUM142 mEq/LPOTASSIUM3.4 mEq/LCHLORIDE103

mEq/LBLOOD UREA23-02-2024 11:38:PM121 mg/dlSERUM CREATININE23-02-2024 11:38:PM3.6

mg/dlSERUM ELECTROLYTES (Na, K, C l) 23-02-2024 11:38:PM SODIUM139

mEq/LPOTASSIUM3.3 mEq/LCHLORIDE101 mEq/LABG 24-02-2024 11:10:AM

PH7.33PCO237.5PO298.2HCO319.6St.HCO320.0BEB-5.1BEecf-5.1TCO241.8O2 Sat84.7O2

Count11.3RFT 24-02-2024 10:23:PM UREA99 mg/dlCREATININE2.7 mg/dlURIC ACID4.3

mg/dlCALCIUM9.8 mg/dlPHOSPHOROUS3.7 mg/dlSODIUM143 mEq/LPOTASSIUM3.6

mEq/LCHLORIDE103 mEq/L

HEMOGRAM : 25/2/24 (8AM)

HB : 18.5

TLC 25000

N/L/E/M/B:91/4/00/5/00

PCV 26.0

MCV 89.7

MCH 29.3

MCHC 32.7

RDW CV 15.6

RDW SD 14.4

RBC COUNT 2.9

PLATELET COUNT : 2.5 LAKHS/CUMM

HEMOGRAM : 25/2/24 (11AM)

HB : 9.1

TLC 26500

N/L/E/M/B:90/4/03/3/00

PCV 26.7

MCV 89.9

MCH 30.6

MCHC 34.1

RDW CV 15.7

RDW SD 52.0

RBC COUNT 2.9

PLATELET COUNT : 2.3 LAKHS/CUMM

USG ABDOMEN :

IMPRESSION : GRADE 2 RPD CHANGES IN LEFT KIDNEY

GRADE 1 RPD CHANGES IN RIGHT KIDNEY

B/L SMALL KIDNEYS

2D ECHO REPORT :

RWMA ,RA HYPOKINESIA

MODERATE MR (ECCENTRIC MR)

MODERATE TR WITH PAH (42 +10 =52 MMHG)

MILD TO MODERATE AR

SCLEROTIC AV NO AS/MS

EF =45

MODERATE LV DYSFUNCTION

GRADE 1 DIASTOLYIC DYSFUNCTION

NO PE

IVC SIZE DILATED NON COLLPASING

DILATED LA/RA/RV

CHEST XRAY AP VIEW DONE ON 22/2/24 :

IMPRESSION - RETICULONODULAR OPACITIES IN B/L LUNG FIELDS - LIKELY

CONSOLIDATORY CHANGES

B/L MILD BLUNTING OF CP ANGLES - ? EFFUSION

PROMINENT RIGHT HILUM - HILAR LYMPHADENOPATHY

ELEVATED RIGHT DOME OF DIAPHRAGM

BLOOD FOR C/S ON 23/2/24 : NO GROWTH AFTER 48 HRS OF AEROBIC INCUBATION

URINE FOR C/S ON 24/2/24 : E. COLI ( >15 CFU/ML )

SENSITIVE TO - GENTAMICIN , PIPERACILLIN/TAZOBACTAM, AMIKACIN, MEROPENEM,

NITROFURANTOIN, NORFLOXACIN

RESISTANT TO - AMOXICLAV, CEFUROXIME, COTRIMOXAZOLE, CIPROFLOXACIN,

CEFEPIME.

CBP(27/2/24)

HAEMOGLOBIN9.4gm/dl

TOTAL COUNT 36,300cells/cumm

NEUTROPHILS 90

LYMPHOCYTES 06

EOSINOPHILS 02

MONOCYTES 02

BASOPHILS 00

PLATELET COUNT 2.5lakhs/cu.mm

SMEAR :Normocytic normochromic anemia

with neutrophilic leukocytosis

RFT(27/2/24)

UREA 74mg/dl

CREATININE 2.1mg/dl

URIC ACID 3.3mg/dl

CALCIUM 9.5mg/dl

PHOSPHOROUS 2.8mg/dl

SODIUM 145mEq/L

POTASSIUM 3.2mEq/L

CHLORIDE 103mEq/L

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1.5 L /DAY

SALT RESTRICTION <2GM / DAY

IVF 1.0 NS @ 50 ML/HR

INJ PIPTAZ 2.25 GM IV/ TID

INJ NOR ADRENALINE 2 AMP IN 46ML NS

@ 2.5 ML /HR TO MAINATAIN MAP >65MMHG

INJ PAN 40 MG IV /OD/ BBF

INJ HAI S/C TID ACC TO GRBS

INJ LASIX 40 MG IV TID

INJ EPO 4000 IU S/C WEEKLY ONCE

INJ IRON SUCROSE 200 MG IN 100 ML NS IV OD

TAB AZITHROMYCIN 500 MG PO/BD

TAB AMLODIPINE 5MG PO/OD

TAB MET - XL 50 MG PO/OD

TAB CARDARONE 200 MG PO/OD

TAB CARVEDILOL 3.125 MG PO/BD

TAB THYRONORM 150 MICRO GRAM PO/OD

TAB NODOSIS 500MG PO/BD

TAB OROFER XT PO/OD

TAB SHELLCAL CT PO/OD

TAB ECOSPIRIN AV 75/10 PO/HS

TA LASIX 40MG PO/BD

GRBS MONITPRING 7 POINT PROFILE

TAB PCM 650MG PO/BD

TAB NORFLOX 200 MG PO BD

SYP CREMAFFIN PLUS 15 ML PO BD

1st Follow up after 4 months

FBS -152 PLBS -189 HBA1c- 7.2

Followup at the end of thesis

FBS -108mg/dl PLBS-175 mg/dl

HBa1c- 7.0

Given the complexity and detail of the provided case, I'll break down the analysis into key components, focusing on coding, categorization, theme identification, and theme representation. This case study seems to revolve around a patient with multiple comorbidities, including diabetes mellitus, hypertension, coronary artery disease, chronic kidney disease, and community-acquired pneumonia, among others.

*Coding*

Initial codes based on key concepts and ideas:

1. Multimorbidity

2. Diabetes Management

3. CKD (Chronic Kidney Disease) Stage 5

4. CAD (Coronary Artery Disease)

5. CAP (Community Acquired Pneumonia)

6. Sepsis

7. Atrial Fibrillation

8. Heart Failure

9. Therapeutic Variability

10. Outcome Influencing Factors

*Categorization*

*Categories and Subcategories:*

1. *Patient Profile*

- Multimorbidity

- Diabetes Mellitus Type 2

- CKD Stage 5

- CAD

2. *Clinical Presentations*

- Community Acquired Pneumonia

- Severe Sepsis with MODS

- Atrial Fibrillation

- Heart Failure

3. *Laboratory Findings*

- Renal Function Tests

- Electrolyte Imbalance

- Blood Sugar Levels

- Blood Culture and Sensitivity

4. *Therapeutic Interventions*

- Medications (Antibiotics, Antidiabetics, Antihypertensives, etc.)

- Fluid and Electrolyte Management

- Dialysis

5. *Outcome and Follow-up*

- Variability in Clinical Response

- Factors Influencing Outcome

- Follow-up Blood Sugar Levels and HBA1c

*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. *Variability in Therapeutic Response:* The patient's response to various treatments (e.g., antibiotics for CAP, management for CKD, and diabetes control) shows variability, emphasizing the need for personalized treatment plans.

3. *Importance of Integrated Care:* The involvement of multiple specialties (cardiology, nephrology, medicine) underscores the importance of coordinated care for patients with multimorbidities.

4. *Impact of Comorbidities on Outcomes:* The case illustrates how comorbid conditions can influence patient outcomes, necessitating careful consideration of all diagnoses when developing treatment plans.

*Theme Representation*

*Learning Points:*

1. *Comprehensive Management Plans:* Patients with multimorbidities require holistic management strategies that consider all their health conditions to optimize outcomes.

2. *Personalized Medicine:* The variability in patient response to treatment highlights the importance of tailoring therapeutic interventions based on individual patient profiles and responses.

3. *Integrated Care Models:* Coordinated care involving multiple specialties can improve outcomes for complex patients by ensuring consistent and comprehensive management plans.

4. *Monitoring and Adjustment:* Continuous monitoring of patients' conditions and adjusting treatment plans accordingly is crucial for managing complex cases effectively.

*New Insights:*

- The case underscores the importance of considering the interplay between different comorbid conditions when managing patients, as treatments targeting one condition can impact others.

- The management of patients with severe sepsis and MODS in the context of chronic diseases like CKD and CAD requires careful fluid management, among other considerations.

- Long-term follow-up data, such as changes in HBA1c levels, provide valuable insights into the effectiveness of diabetes management strategies in patients with complex medical histories.

This analysis provides a structured approach to understanding the complexities involved in managing a patient with multiple comorbidities, highlighting the importance of integrated, personalized care and comprehensive management plans.