Case 27:75 M with difficulty in speech ,Generalised weakness

Doa 27/6/24

Expired on 6/7/24

Diagnosis

TYPE 1 RESPIRATORY FAILURE

CARDIOGENIC SHOCK SECONDARY TO ATRIAL FIBRILLATION WITH FAST VENTRICULAR

RATE SECONDARY TO ISCHEMIC HEART DISEASE

ALTERED SENSORIUM SECONDARY TO HYPONATREMIA

SEPTIC SHOCK SECONDARY TO ACUTE GE

ACUTE KIDNEY INJURY SECONDARY TO GE

CHRONIC LIVER DISEASE

GRADE 2 BED SORE

RIGHT OA KNEE WITH INFECTIVE SYNOVITIS

KNOWN CASE OF HYPERTENSION

TYPE 2 DIABETES MELLITUS

Case History and Clinical Findings

C/O DIFFICULTY IN SPEECH SINCE 2 DAYS

C/O GENERALISED WEAKNESS SINCE 2 DAYS

C/O 4 EPISODES OF LOOSE STOOL SINCE TODAY

HOPI:PATIENT WAS APPRENTLY ASYMPTOMATIC 2 DAYS AGO THEN HE DEVELOPED

DIFFICULTY IN SPEECH , DYSPHAGIA TO SOLIDS THEN LIQUIDS AND DECREASED

APPETITE.C/O GENERALISED WEAKNESS SINCE 2 DAYS , C/O 4 EPISODES LOOSE STOOLS ,

NON FOUL SMELLING , WATERY IN CONSISTENCY , NO ASSOCIATED WITH PAUIN

ABDOMEN, NAUSEA.

NO C/O CHEST PAIN , APLPITATIONS , ORTHOPNOEA , PND

PAST HISTORY:

K/C/O HTN SINCE 5 YEARS AND ON T.METOPROLOL 50 MG , T.TELMA 40 MG

K/C/O DM SINCE 5 YEARS AND ON T.GLIMEPIRIDE 2 MG , T.METFORMIN 500 MG

NO A K/C/O CAD, CVA , TB , ASTHMA , EPILEPSY

PERSONAL HISTORY:

DIET - MIXED

APPETITE - DECREASED

BOWEL AND BLADDER - REGULAR AND NORMAL

NO HABITS

GENERAL PHYSICAL EXAMINATION:

PATIENT IS CONSCIOUS , COHERENT AND COOPERATIVE

NO PALLOR , ICTERUS , CYANOSIS , CLUBBING ,LYMPHADENOPATHY, EDEMA

TEMPERATURE - 98.6 F

PULSE RATE - 135 BPM

RESPIRATORY RATE - 28 CPM

BP - 110/70 MMHG

SPO2 - 99% AT RA

GRBS - 156 MG%

SYSTEMIC EXAMINATION:CVS - S1S2 + , NO MURMURS

RS - BAE + , NVBS HEARD

CNS - NFND

P/A - SOFT AND NON TENDER

Investigation

HBsAg-RAPID 27-06-2024 09:18:PM Negative

Anti HCV Antibodies - RAPID 27-06-2024 09:18:PM Non ReactiveRFT 27-06-2024 09:18:PMUREA

42 mg/dl 50-17 mg/dlCREATININE 1.2 mg/dl 1.3-0.8 mg/dlURIC ACID 2.5 mmol/L 7.2-3.5

mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.0 mg/dl 4.5-2.5 mg/dlSODIUM 126

mmol/L 145-136 mmol/LPOTASSIUM 4.2 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 83 mmol/L 98-107

mmol/L

LIVER FUNCTION TEST (LFT) 27-06-2024 09:18:PMTotal Bilurubin 2.39 mg/dl 1-0 mg/dlDirect

Bilurubin 1.43 mg/dl 0.2-0.0 mg/dlSGOT(AST) 86 IU/L 35-0 IU/LSGPT(ALT) 49 IU/L 45-0

IU/LALKALINE PHOSPHATASE 499 IU/L 119-56 IU/LTOTAL PROTEINS 5.7 gm/dl 8.3-6.4

gm/dlALBUMIN 2.71 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.91COMPLETE URINE EXAMINATION (CUE)

27-06-2024 09:18:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY

1.010ALBUMIN TraceSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL

CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS

AbsentOTHERS Nil

ABG 27-06-2024 09:53:PMPH 7.502PCO2 16.0PO2 73.0HCO3 12.5St.HCO3 17.9BEB -8.1BEecf -

10.3TCO2 24.1O2 Sat 95.2O2 Count 18.6RFT 28-06-2024 05:57:AMUREA 54 mg/dl 50-17

mg/dlCREATININE 1.2 mg/dl 1.3-0.8 mg/dlURIC ACID 2.7 mmol/L 7.2-3.5 mmol/LCALCIUM 9.8

mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.7 mg/dl 4.5-2.5 mg/dlSODIUM 126 mmol/L 145-136

mmol/LPOTASSIUM 4.2 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 83 mmol/L 98-107 mmol/L

SERUM ELECTROLYTES (Na, K, C l) 28-06-2024 04:19:PMSODIUM 126 mmol/L 145-136

mmol/LPOTASSIUM 4.0 mmol/L 5.1-3.5 mmol/LCHLORIDE 96 mmol/L 98-107 mmol/LSERUM

ELECTROLYTES (Na, K, C l) 28-06-2024 04:24:PMSODIUM 117 mmol/L 145-136

mmol/LPOTASSIUM 4.3 mmol/L 5.1-3.5 mmol/LCHLORIDE 91 mmol/L 98-107 mmol/L

RFT 28-06-2024 11:08:PMUREA 89 mg/dl 50-17 mg/dlCREATININE 1.6 mg/dl 1.3-0.8 mg/dlURIC

ACID 3.8 mmol/L 7.2-3.5 mmol/LCALCIUM 9.3 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.4 mg/dl 4.5-

2.5 mg/dlSODIUM 132 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

99 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 28-06-2024 11:08:PMTotal Bilurubin 1.64

mg/dl 1-0 mg/dlDirect Bilurubin 0.86 mg/dl 0.2-0.0 mg/dlSGOT(AST) 121 IU/L 35-0 IU/LSGPT(ALT)

63 IU/L 45-0 IU/LALKALINE PHOSPHATASE 366 IU/L 119-56 IU/LTOTAL PROTEINS 5.0 gm/dl 8.3-

6.4 gm/dlALBUMIN 2.28 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.84

ABG 29-06-2024 03:03:PMPH 7.36PCO2 12.0PO2 93.5HCO3 6.7St.HCO3 12.4BEB -16.7BEecf -

18.3TCO2 13.1O2 Sat 96.2O2 Count 20.4SERUM ELECTROLYTES (Na, K, C l) 29-06-2024

06:00:PMSODIUM 126 mmol/L 145-136 mmol/LPOTASSIUM 4.2 mmol/L 5.1-3.5 mmol/LCHLORIDE

98 mmol/L 98-107 mmol/L

RFT 29-06-2024 10:09:PMUREA 124 mg/dl 50-17 mg/dlCREATININE 1.8 mg/dl 1.3-0.8 mg/dlURIC

ACID 4.9 mmol/L 7.2-3.5 mmol/LCALCIUM 9.7 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.6 mg/dl 4.5-

2.5 mg/dlSODIUM 127 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

98 mmol/L 98-107 mmol/LSERUM ELECTROLYTES (Na, K, C l) 30-06-2024 12:01:AMSODIUM 128

mmol/L 145-136 mmol/LPOTASSIUM 4.2 mmol/L 5.1-3.5 mmol/LCHLORIDE 101 mmol/L 98-107

mmol/L

ABG 30-06-2024 12:01:AMPH 7.384PCO2 11.2PO2 120HCO3 6.5St.HCO3 12.0BEB -16.9BEecf -

18.3TCO2 13.2O2 Sat 97.0O2 Count 17.4

06/07/2024

HEMOGRAM

HB 8.3MG/DL

TLC 16,400

NEUTROPHILS 82

EOSINOPHILS 0

MONOCYTE 5

LYMPHOCYTES 6

PLATELETS1.5L/MM3

RBC 2.77

Treatment Given(Enter only Generic Name)

RT FEEDS - 100ML MILK 4TH HRLY , 100 ML WATER 2ND HRLY

IV FLUIDS PLASMALYTE/ RL @ 75 ML/HR

INJ.NORADRENALINE 2 AMP (0.16 MICROGM/ML) IN 46 ML NS @ 4 ML /HR INCREASED OR

DECREASED ACC.TO MAINATAIN MAP >OR= 65 MMHG

INF.DOBUTAMINE 1AMPULE IN 45ML NS AT 3.6ML/HR INCREASED OR DECREASED ACC.TO

MAINATAIN MAP >OR= 65 MMHG

INJ.VASOPRESSIN 2 AMPULES IN 38ML NS IV AT 2.4ML/HR INCREASED OR DECREASED

ACC.TO MAINATAIN MAP >OR= 65 MMHG

INJ.PIPTAZ 2.25 GM/IV/QID

INJ.MAGNEX FORTE 1.5GM IV/BD

INJ.PANTOP 40 MG IV/OD /BBF

INJ.KCL 2 AMPULES + 1 AMPULE MGSO4 IN 500ML NS SLOWLY OVER 5-6 HOURS

INJ.CLEXANE 60 MG S/C/OD

INJ.HAI S/C TID ACC TO GRBS

INJ.LASIX 40 MG IV/BD

INJ.DILTIAZEM 20 MG IV/STAT F/B TAB .DILTIAZEM 30 MG RT/BD

TAB.NODOSIS 500 MG RT/BD

TAB.TOLVAPTAN 15 MG RT/OD

TAB.CARDARONE 200 MG RT/BD

TAB.UDILIV 300 MG RT/BD

TAB.DIGOXIN 0.25MG RT/OD

TAB.MET- XL 50MG RT/BD

TAB.THYRONORM 25MCG RT/OD

OINT.THROMBOPHOBE FOR LOCAL APPLICATION/ TID

REGULAR BED SORE DRESSING

2ND HOURLY POSITION CHANGE

STRICT I/O CHARTING

GRBS 7TH HOURLY

Advice at Discharge

DEATH SUMMARY:

A 75 YR OLD MALE KNOWN TO BE HYPERTENSIVE,DIABETIC MELLITUS TYPE 2 CAME TO

CASUALTY WITH COMPLAINTS OF 4 EPSIODES OF LOOSE STOOLS,GENERALISED

WEAKNESS, ALTERED SENSORIUM SINCE 2 DAYS AND,H/O FALL FROM BED 20 DAYS

BACK.ECG SHOWED ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE AND 1CC

METOPROLOL IV/STAT WAS GIVEN.PATIENT WAS IN ALTERED SENSORIUM AND ON MRI

SHOWING DIFFUSE CEREBRAL ATROPHY. ON FURTHER INVESTIGATIONS, SERUM SODIUM-

126,POTASSIUM-4.2,CHLORIDE-83 SERUM OSMOLALITY-257 AND WAS STARTED ON 0.9 %

NACL INFUSION. ON DAY 2 2D ECHO SHOWED RWMA, LAD TERRITORY. ECG SHOWED

ATRIAL FIBRILLATION WITH FAST VENTRICULAR RATE WAS PERSISTENT AND WAS

STARTED ON AMIODARONE INFUSION AND ANTI COAGULANTS. ON DAY 3, I/V/O

PERSISTENT HIGH HEART RATE AND HYPOTENSION, ON TAKING ADVICE OF

CARDIOLOGIST, STARTED ON DIGOXIN,CARDARON,DILTIAZEM,INOTROPES TO CONTROL

HEART RATE. ON DAY4 HYPOTENSION PERSISTED, CENTRAL LINE WAS PLACED AND

STARTED ON DUAL INOTROPIC SUPPORT AS ADVISED BY CARDIOLOGIST. TOLVAPTAN

WAS STARTED I/V/O PERSISTENT HYPONATREMIA. PATIENT HAD CONTINUOUS FEVER

SPIKES BUT BLOOD AND URINE CULTURES WERE NEGATIVE.PATIENT HAD RIGHT KNEE

SWELLING FOR WHICH ORTHO OPINION WAS TAKEN AND SYNOVIAL FLUID ASPIRATION

WAS DONE AND SHOWED GROWTH OF ACINITOBACTER AND WAS MANAGED

CONSERVATIVELY.THE PATIENT DEVELOPED GRADE 2 BED SORE ON BILATERAL GLUTEAL

REGION AND SURGERY OPINION WAS TAKEN AND MANAGED ACCORDINGLY. DAY 5, I/V/O

PERSISTENT HYPOTENSION, CARDILOGIST REVIEW WAS TAKEN AND ADVISED TO STOP

DILTIAZEM, DIGOXIN AND NOR ADRENALINE AND WAS STARTED ON VASOPRESSIN. ON

DAY6, PATIENT WAS DROWSY AND REVIEW 2D ECHO SHOWED 0 SHAPED LV,

PARADOXICAL MS, EF:53% FAIR LV FAIR LV SYSTOLIC FUNCTION AND GRADE 1 DIASTOLIC

DYSFUNCTION. ON DAY 7 PATIENT WAS DROWSY, WITH ATRIAL FIBRILLATION WITH FAST

VENTRICULAR RATE AND HYPOTENSION STILL PERSISTING AND HIS BED SORE WAS

WORSENING EVEN AFTER ADEQUATE POSITION CHANGE AND REGULAR DRESSINGS. DAY

8, THE CONDITION OF THE PATIENT WAS STILL SAME. ON DAY 9, PATIENT WAS DROWSY AND DEVELOPED SUDDEN BRADYCARDIA FALL IN SATURATION,

EMERGENCY INTUBATION WAS DONE AND CPR WAS INITIATED SIMULTANEOUSLY.

DESPITE ALL THE EFFORT THE PATIENT COULD NOT BE REVIVED AND WAS DECLARED

DEAD WITH FLAT LINE ECG ON 06.07.24 AT 9:20AM

IMMEDIATE CAUSE:

TYPE 1 RESPIRATORY FAILURE

CARDIOGENIC SHOCK SECONDARY TO ATRIAL FIBRILLATION WITH FAST VENTRICULAR

RATE SECONDARY TO ISCHEMIC HEART DISEASE

ANTECEDENT CAUSE:

ALTERED SENSORIUM SECONDARY TO HYPONATREMIA

SEPTIC SHOCK SECONDARY TO ACUTE GE

ACUTE KIDNEY INJURY SECONDARY TO GE

CHRONIC LIVER DISEASE

GRADE 2 BED SORE

KNOWN CASE OF HYPERTENSION

TYPE 2 DIABETES MELLITUS