Case 25. 56 Male with low back ache

Doa 29/8/23

Date of death 18/9/23

Diagnosis

HEART FAILURE WITH MID RANGE EJECTION FRACTION( EF 44%) WITH RIGHT LOWER LOBE

COLLAPSE WITH BRONCHIECTASIS WITH RIGHT MIDDLE LOBE PLEURAL EFUSION WITH

CHRONIC PANCREATITIS WITH SEPSIS WITH GRADE 2 BED SORE WITH K/C/O DM II SINCE 20 YEARS ,KC/O HTN SINCE 15 YEARS WITH K/C/O CAD-S/P: PTCA DONE 2 YEARS AGO

D9-S/P: TRACHEOSTOMY

Case History and Clinical Findings

PATIENT CAME WITH C/O LOWER BACK ACHE SINCE 3 WEEKS RADIATING TO LEFT LOWER

LIMB

HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIOC 3 WEEKS BACK SINCE THEN, PATIENT

COMPLAINTS OF LOWER BACK ACHE WHICH IS SUDDEN ONSET,NON

PROGRESSIVE,AGRAVATES ON MOVEMENT RELEIVES ON REST

H/O TRAUMA(SLIP AND FALL FROM STEPS) 3 WEEKS BACK ,WAS TAKEN TO OUTSIDE

HOSPITAL FOUND TO HAVE L5 BURST FRACTURE ON CT PELVIS AND CAME HERE FOR

FURTHER MANAGEMENT

NO H/O LIFTING OF HEAVY WEIGHTS,FEVER BURNING MICTURITION BOWEL AND BLADDER

INCONTINENCE

PAST HISTORY OF RIGHT PROXIMAL FEMUR FRACTURE AND DONE IMILN 10 YEARS BACK.

H/O PTCA DONE ONE AND HALF YEAR BACK AND IS ON REGULAR MEDICATION

K/C/O DM II SINCE 20 YEARS AND IS ON T. METFORMIN 500 MG + T. VOGLIBOSE 0.2 MG + T. GLIMIPERIDE 2 MG

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT AND CO OPERATIVE

NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,EDEMA AND LYMPHADENOPATHY

VITALS:

TEMP:AFEBRILE

BP: 110/80MMHG

PR:80BPM

RR:18CPM

SYSTEMIC EXAMINATION:

CVS: S1,S2+; NO MURMURS

CNS:NAD

RS:NVBS +

P/A : SOFT,NON TENDER

B/L OF LS SPINE:

SKIN: NORMAL

SWELLING: ABSENT

TENDERNESS: PRESENT AT LUMBAR REGION

TRACHEOSTOMY WAS DONE ON 6/9/23

BLOOD TRANSFUSION WAS DONE ON 12/9/23

PULMONOLOGY REFERRAL WAS DONE ON 30/8/23 AND ADVISED FOR CT CHEST AND

INDUCED SPUTUM FOR CBNAAT AND CULTURE SENSITIVITY

NEPHROLOGY REFERRAL WAS DONE ON 2/9/23 AND ADVISED FOR HAEMODIALYSIS

PULMONOLOGY REFERRAL WAS DONE ON 2/9/23 AND ADVISED FOR USG GUIDED TAP AND

ICD PLACEMENT

SURGERY REFERRAL WAS DONE 4/9/23 AND ADVISED FOR ASEPTIC DRESSINGS, CHANGE

OF POSITION 4 HOURLY AND ALPHA BED

SURGERY REFERRAL WAS DONE 6/9/23 AND ADVISED FOR ASEPTIC DRESSINGS, CHANGE

OF POSITION 2 HOURLY AND ALPHA BED

Investigation

RFT 29-08-2023 01:11:PM

UREA

77 mg/dl

42-12 mg/dl

CREATININE

1.1 mg/dl

1.3-0.9 mg/dl

URIC ACID

2.9 mg/dl

7.2-3.5 mg/dl

CALCIUM

8.8 mg/dl

10.2-8.6 mg/dl

PHOSPHOROUS

4.8 mg/dl

4.5-2.5 mg/dl

SODIUM

121 mEq/L

145-136 mEq/L

POTASSIUM

4.6 mEq/L

5.1-3.5 mEq/L

CHLORIDE

95 mEq/L

98-107 mEq/L

LIVER FUNCTION TEST (LFT) 29-08-2023 01:11:PM

Total Bilurubin

0.76 mg/dl

1-0 mg/dl

Direct Bilurubin

0.19 mg/dl

0.2-0.0 mg/dl

SGOT(AST)

11 IU/L

35-0 IU/L

SGPT(ALT)

13 IU/L

45-0 IU/L

ALKALINE PHOSPHATE

321 IU/L

128-53 IU/L

TOTAL PROTEINS

5.0 gm/dl

8.3-6.4 gm/dl

ALBUMIN

2.59 gm/dl

5.2-3.5 gm/dl

A/G RATIO

1.02

HBsAg-RAPID29-08-2023 01:11:PM

Negative

Anti HCV Antibodies - RAPID29-08-2023 01:11:PM

Non Reactive

COMPLETE BLOOD PICTURE (CBP) 29-08-2023 01:11:PM

HAEMOGLOBIN

9.0 gm/dl

17.0-13.0 gm/dl

TOTAL COUNT

15300 cells/cumm

10000-4000 cells/cumm

NEUTROPHILS

87 %

80-40 %

LYMPHOCYTES

10 %

40-20 %

EOSINOPHILS

01 %

6-1 %

MONOCYTES

02 %

10-2 %

BASOPHILS

00 %

2-0 %

PLATELET COUNT

1.8

SMEAR

Normocytic normochromic Anemia with neutrophilic leucocytosis

COMPLETE URINE EXAMINATION (CUE) 29-08-2023 01:11:PM

COLOUR

Pale yellow

APPEARANCE

Clear

REACTION

Acidic

SP.GRAVITY

1.010

ALBUMIN

+

SUGAR

++++

BILE SALTS

Nil

BILE PIGMENTS

Nil

PUS CELLS

2-4

EPITHELIAL CELLS

2-3

RED BLOOD CELLS

Nil

CRYSTALS

Nil

CASTS

Nil

AMORPHOUS DEPOSITS

Absent

OTHERS

Nil

ABG 29-08-2023 08:07:PM

PH

7.43

PCO2

27.6

PO2

48.1

HCO3

18.3

St.HCO3

20.5

BEB

-4.5

BEecf

-5.2

TCO2

37.7

O2 Sat

86.1

O2 Count

12.4

SODIUM

122 mEq/L

145-136 mEq/L

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 30-08-2023 12:35:PM

POTASSIUM

4.1 mEq/L

5.1-3.5 mEq/L

CHLORIDE

95 mEq/L

98-107 mEq/L

CALCIUM IONIZED

1.02 mmol/L

mmol/L

SODIUM

124 mEq/L

145-136 mEq/L

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 30-08-2023 03:35:PM

POTASSIUM

4.4 mEq/L

5.1-3.5 mEq/L

CHLORIDE

94 mEq/L

98-107 mEq/L

CALCIUM IONIZED

1.12 mmol/L

mmol/L

ABG 30-08-2023 04:29:PM

PH

7.34

PCO2

31.4

PO2

58.4

HCO3

16.7

St.HCO3

18.2

BEB

-7.6

BEecf

-7.9

TCO2

34.2

O2 Sat

89.7

O2 Count

15.2

SODIUM

135 mEq/L

145-136 mEq/L

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 30-08-2023 09:03:PM

POTASSIUM

5.0 mEq/L

5.1-3.5 mEq/L

CHLORIDE

99 mEq/L

98-107 mEq/L

CALCIUM IONIZED

1.11 mmol/L

FBS 176 mg/dl

PLBS 200 mg/dl Hba1c -6.9%

HEMOGRAM:

30/8/23

HEMOGLOBIN: 8.9 MG/DL

TLC: 30,000 CELLS/CUMM

PLT:2.4 LAKHS/CUMM

2/9/23

HEMOGLOBIN:7.2 MG/DL

TLC: 22,00 CELLS/CUMM

PLT:1.5 LAKHS/CUMM

5/9/23

HEMOGLOBIN: 7.0 MG/DL

TLC: 23,600 CELLS/CUMM

PLT: 1.63 LAKHS/CUMM

8/9/23

HEMOGLOBIN: 6.9 MG/DL

TLC: 24,300 CELLS/CUMM

PLT: 2.6 LAKHS/CUMM

12/9/23

HEMOGLOBIN: 6.5 MG/DL

TLC: 20,500 CELLS/CUMM

PLT: 2.43 LAKHS/CUMM

15/9/23

HEMOGLOBIN: 6.2 MG/DL

TLC: 19,200 CELLS/CUMM

PLT: 1.5 LAKHS/CUMM

2D ECHO (30/8/23)

- TACHYCARDIA, MILD LHF

-RWMA; APEX, ANTERIOR WALL AND LATERAL WALL HYPOKINESIA

- TRIVIAL MR/AR, NO TR

- SCLEROTIC AV, NO AS/MS

- EF= 44%, MODERATE LV DYSFUNCTION

- NO DIASTOLIC DYSFUNCTION, NO PAH/PE

HRCT OF CHEST (31/8/23)

- RIGHT LOWER LOBE COLLAPSE WITH BRONCHIECTASIS

- FOCI OF CONSOLIDATION IN RIGHT MIDDLE LOBE, LINGULA AND APICAL SEGMENT OF

LEFT LUNG LOWER LOBE

- LARGE LOCULATED RIGHT PLEURAL EFFUSION EXTENDING INTO THE MAJOR FISSURE.

- A POCKET OF LOCULATED MEDIASTINAL PLEURAL EFFUSION ON RIGHT SIDE

- CHRONIC CALCIFIC PANCREATITIS

USG ABDOMEN 2/9/23

NO SONOLOGICAL ABNORMALITY DETECTED

Treatment Given(Enter only Generic Name)

1.INJ.LEVIPIL 1GM IV/BD FOR 16 DAYS

2. INJ. NORAD AT 1.1 ML/HR FOR 7 DAY

3.INJ. DOBUTAMAMINE IV FOR 7 DAYS

4.INJ. VASOPRESSIN AT .5 ML/HR FOR 6 DAYS

5.FENTANYL+ MIDAZOLAM FOR 8 DAYS

6.INJ. HEPAIN FOR 13 DAYS

7.TAB. TOLVAPTAN FOR 6 DAYS

8.INJ. THIAMINE FOR 7 DAYS

9.INJ. HAI FOR 16 DAYS

10.INJ. PIPTAZ 2.25 GMS IV/TID FOR 5 DAYS

11.TAB.ATORVASTATIN+ ASPIRIN 75 MG RT/HS FOR 16 DAYS

12. TAB. OROFER XT RT/OD FOR 16 DAYS

13.NEBULIZATION WITH IPRAVENT 6TH HOURLY AND BUDECORT 4TH HOURLY FOR 16

DAYS

14.INJ.MEROPENEM 500MG IV/BD FOR 12 DAYS

15.TAB.FLUCONAZOLE 150MG RT/OD FOR 8 DAYS

16.INJ.VANCOMYCIN 500MG IV/BD FOR 5 DAYS

17.CHANGE OF POSITION 2 HRLY AND DAILY DRESSING OF BED SORE

Follow Up

DEATH SUMMARY

A 55 YEAR OLD MALE WITH L5 (UNSTABLE) BURST FRACTURE (3 WEEKS) OLD AND WAS

TRANSFERRED FROM ORTHOPEDICS TO GENERAL MEDICINE I/V/O HIGH GRBS. PATIENT

SUGARS WERE CONTROLLED WITH INSULIN INFUSION AND HANDED OVER TO

ORTHOPEDICS. AFTER 1 HR PATIENT DEVELOPED ALTERED SENSORIUM AND

TRANSFERED TO GENERAL MEDICINE, ALTERED SENSORIUM MIGHT BE DUE TO

?HYPONATREMIA WHICH WAS CORRECTED WITH 3% NACL.

NEXT DAY I/V/O FALLING SATURATION PATIENT WAS INTUBATED. HE ALSO HAD

BRADYCARDIA AT THAT TIME FOR WHICH CPR WAS INITIATED,AND PATIENT REVIVED. AS

THERE WERE DECREASED BREATH SOUNDS ON RIGHT SIDE OF CHEST, HRCT CHEST WAS

DONE ON 31/8/23 ON WHICH PATIENT WAS FOUND TO HAVE RIGHT LOWER LOBE

COLLAPSE WITH BRONCHIECTASIS, LARGE LOCULATED PLEURAL EFFUSION, EXTENDING

INTO MAJOR FISSURE, POCKET OF LOCULATED MEDIASTINAL EFFUSION ON RIGHT SIDE

WITH CHRONIC CALCIFIC PANCREATITIS.

PATIENT DEVELOPED HEART FAILURE WITH EJECTION FRACTION 44% (INITIALLY 65%). D-

DIMER FOUND TO BE ELEVATED INITIALLY, PULMONARY EMBOLISM WAS SUSPECTED AND

HEPARIN WAS ADDED TO THE TREATMENT. PATIENT HAD HYPOTENSION FOR WHICH HE

WAS PLACED ON IONOTROPE SUPPORT. AS THERE WERE RAISED TLC AND FEVER SPIKES

IN BETWEEN . PATIENT WAS STARTED ON ANTIBIOTICS.

PATIENT HAS DECREASED URINE OUTPUT AND INCREASED SERUM UREA AND CRETININE.

DIURETICS WERE ADDED TO THE TREATMENT AND GRADUALLY HIS URINE OUTPUT WAS

INCREASED. HE WAS MAINTAINED ON VENTILATOR AND TRIPLE IONOTROPE SUPPORT. HIS

BLOOD PRESSURE WAS GRADUALLY IMPROVED AND TRIPLE IONOTROPE SUPPORT WAS

TAPERED GRADUALLY.

PATIENT HAD RECURRENT EPISODES OF SEIZURES(DUE TO ?HYPOXIC ISCHEMIC

ENCEPHALOPATHY) IN BETWEEN AND WAS CONTROLLED WITH ANTIEPILEPTICS.

ON 6/9/23 PATIENT WAS TRACHEOSTOMISED AND MAITAINED ON VENTILATOR.