Case 33 60 Male with swelling of rt leg

Doa 19/7/2024

Expired on 9/8/24

Diagnosis

SEVERE METABOLIC ACIDOSIS WITH TYPE II RESPIRATORY FAILURE

REFRACTORY HYPOTENSION

SEPTIC SHOCK WITH MODS

NECROTISING FASCITIS S/P FASCIOTOMY + DEBRIDEMENT

CHRONIC LIVER DISEASE

ANEMIA OF CHRONIC DISEASE

HFPEF

K/C/O DM-II

K/C/O HYPERTENSION

Case History and Clinical Findings

C/O SWELLING OF RIGHT LEG SINCE 4 DAYS

C/O MULTIPLE BELBS OVER POSTERIOR ASPECT OF RIGHT LEG SINCE 4 DAYS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 DAYS AGO THEN HE NOTICED SWELLING

OVER RIGHT LEG WHICH WAS INSIIOUS ONSET, GRADUALLY PROGRESSIVE ASSOCIATED

WITH BLEBS OVE POSTERIOR ASPECT OF RIGHT LEG ASSOCIATED WITH BLACK

DISCHARGE

H/O FEVER LOW GRADE INTERMITTENT RELIEVED ON MEDICATION

C/O PAIN PRESENT PRICKING TYPE, NON RADIATING, INTERITTEENT, AGGREVATED ON

WALKING, RELIEVED ON REST

PAST HISTORY:

K/C/O DENOVO DM POSITIVE NOT ON MEDICATION

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

PERSONAL HISTORY:

DIET MIXED

APPETITE NORMAL

NORMAL BOWEL AND BLADDER MOVEMENTS

GENERAL EXAMINATION:

PATIENT IS CONCIOUS COHORENT COOPERATIVE

NO PALLOR, CTERUS, CYANOSIS, PEDAL EDEMA, CLUBBING

BP: 100/60 mm hg

PR:68 bpm

SPO2:92%

RR:26 cpm

SYSTEMIC EXAMINATION:

RS: NVBS+, BAE+

CVS: S1 S2 HEARD

CNS NFND

ON EXAMINATION:

SWELLING OF RIGHT LEG EXTENDING FROM KNEE JOINT

SKIN OVER THE RIGHT LEG IS ERYTHEMATOUS AND SHINY

LOSS OF HAIR OVER RIGHT LEG PRESENT

NO SCARS OR SINUSES

MULTIPLE BLEBS OF SIZE 2X2CM, 1X1CM AND 1X2 CM ARE PRESENT OVER THE

POSTERIOR ASPECTS OF UPPER HALF OF RIGHT LEG WITH ACTIVE BLACK

DISCOLOURATION WITH SEROUS DISCHARGE

SKIN OVER THE POSTERIOR ASPECT OF RIGHT LEG IS HYPERPIGMENTED

NO ENGORGED VEINS

OPPOSITE LIMB APPEARS NORMAL

ON PALPATION:

LOCAL RISE OF TEMPERATURE PRESENT UPTIL KNEE JOINT

TENDERNESS PRESENT

PITTING EDEMA PRESENT EXTEDING FROM ANKLE JOINT UPTO KNEE JOINT

BLEBS PRESENT OVER POSTERIOR ASPECT OF RIGHT LEG WITH POSITIVE FLUCTUATION

TEST

JOINT MOVEMENTS NORMAL

ALL INSPECTORY FINDINGS ARE CONFIRMED ON PALPATION

PERIPHERAL PULSES ATA, PTA, DPA FELT

OPPOSITE LIMB NORMAL

PULMONOLOGY REFERRAL DONE ON 5/8/24 I/V/O SOB AND CHEST XRAY S/O PLEURAL

EFFUSION

ADVICE USG CHEST

RX

CONTINUE SAME TREATMENT

REVIEW WITH USG CHEST REPORT

RX: CONTINUE SAME TREATMENT

Investigation

ON 19/7/24CBPHAEMOGLOBIN 12.6gm/dlTOTAL COUNT 18,400 Ncells/cummNEUTROPHILS

85%LYMPHOCYTES 04%EOSINOPHILS 01%MONOCYTES 10%BASOPHILS 0%PLATELET

COUNT1.20lakhs/cu.mmSMEARNormocytic normochromic withneutrophilic leukocytosis

andthrombocytopeniaSERUM ELECTROLYTES

SERUM NA:135

SERUM K:4

SERUM CL: 98

SERUM CA: 1.05

APTT: 33SEC

PT: 16SE

INR: 1.11

FBS: 155MG/DL

PLBS: 202 MG/DL

HB1AC: 6.8%

BT: 2MIN

CT: 5MIN

BGT: O+VE

SERUM CREATININE: 4.3MG/DL

BLOOD UREA: 89MG/DL

22/7/24

BLEBS FLUID CULTURE

GRAM STAIN: MODERATE NUMBER OF PUS CELLS, GRAM POSITIVE COCCI IN CHAINS SEEN

REPORT: STREPTOCCCUS PYOGENS ISOLATED

ABGPH 7.44PCO2 26.4mmHgPO2 74.2mmHgHCO3 17.7mmol/LSt.HCO3 20.6 mmol/LBEB -

4.6mmol/LBEecf -5.7 mmol/LTCO2 34.5VOLO2 Sat 94.1%O2 Count 18.4 vol %LFTTotal Bilurubin

6.23 mg/dlDirect Bilurubin 4.58mg/dlSGOT(AST) 61IU/LSGPT(ALT) 20

IU/LALKALINEPHOSPHATASE 307 IU/LTOTAL PROTEINS 5.0 gm/dlALBUMIN 2.1gm/dlA/G RATIO

0.72HEMOGRAM AT 7AMHAEMOGLOBIN10.8gm/dl13.0 - 17.0ColorimetricTOTAL

COUNT20,370cells/cumm4000 - 10000ImpedenceNEUTROPHILS86%40 - 80Light

MicroscopyLYMPHOCYTES04%20 - 40Light MicroscopyEOSINOPHILS02%01 - 06Light

MicroscopyMONOCYTES08%02 - 10Light MicroscopyBASOPHILS00%0 - 2Light

MicroscopyPCV29.6vol %40 - 50CalculationM C V91.1fl83 - 101CalculationM C H33.2pg27 -

32CalculationM C H C36.5%31.5 - 34.5CalculationRDW-CV17.0%11.6 - 14.0HistogramRDW-

SD57.2fl39.0-46.0HistogramRBC COUNT3.25millions/cumm4.5 - 5.5ImpedencePLATELET

COUNT1.2lakhs/cu.mm1.5-4.1ImpedenceSMEARRBCNormocytic normochromic with fewmicrocytes

and macrocytesLight MicroscopyWBCincreased counts on smear withabsolute neutrophiliaLight

MicroscopyPLATELETSdecreased counts on smearplatelets clumps seenLight

MicroscopyHEMOPARASITESNo hemoparasites seenLight MicroscopyIMPRESSIONNormocytic

normochromic anemiawith neutrophilic leucocytosis andmild thrombocytopeniaHEMOGRAM AT

3.27PMHAEMOGLOBIN11.9gm/dlTOTAL COUNT 20,100NEUTROPHILS 86 %LYMPHOCYTES 05

%EOSINOPHILS 01 %MONOCYTES 08 %BASOPHILS 00 %PCV 32.5 vol %M C V 90.8flM C H

33.2pgM C H C 36.6%RDW-CV 17.1%RDW-SD 57.5 flRBC COUNT 3.58 millions/cummPLATELET

COUNT 1.2 lakhs/cu.mmSMEARRBCNormocytic normochromicWBC increased count with

absoluteneutrophilia left shift , band forms ,meta myelocytesPLATELETS

InadequateHEMOPARASITES No hemoparasites seenIMPRESSIONNormocytic normochromic

blood picture with leukemoid reaction and moderate thrombocytopeniaSERUM CREATININE

2.6MG/DLSERUM UREA 148 MG/DLSERUM NA 137 MMOL/LSERUM CL 101MMOL/LSERUM K

3.5 MMOL/LSERUM CA 1.16BT 2MIN 30SECCT 5 MINPT 16SECINR 1.11CRP- POSITIVE

4.8MG/DL

ON 27/7/24

CBPHAEMOGLOBIN9.6gm/dl13.0 - 17.0ColorimetricTOTAL COUNT16,900cells/cumm4000 -

10000ImpedenceNEUTROPHILS87%40 - 80Light MicroscopyLYMPHOCYTES06%20 - 40Light

MicroscopyEOSINOPHILS03%1 - 6Light MicroscopyMONOCYTES04%2 - 10Light

MicroscopyBASOPHILS00%0 - 2Light MicroscopyPLATELET COUNT1.84lakhs/cu.mm1.5-

4.1ImpedenceSMEARNormocytic normochromic anemiawith neutrophilic leukocytosisLFTTotal

Bilurubin6.27mg/dl0 - 1Jendrassic &Groff'sDirect Bilurubin5.41mg/dl0.0 - 0.2Jendrassic

&Groff'sSGOT(AST)52IU/L0 - 35Modified IFCCSGPT(ALT)21IU/L0 - 45Modified

IFCCALKALINEPHOSPHATASE269IU/L56 - 119PNPP-DEATOTAL PROTEINS6.1gm/dl6.4 -

8.3BiuretALBUMIN1.6gm/dl3.2 - 4.6BCGA/G RATIO0.35SERUM CREATININE: 1.0MG/DLSERUM

UREA: 37SERUM NA: 131MMOL/LSERUM CL: 4.4 MMOL/LSERUM CL 101 MMOL/LSERUM

CALCIUM 1.20ON 23/7/24TISSUE FOR C/SMODERATE NUMBER OF PUS CELLS, GRAM

POSITIVE COCI IN PAIRS SEENREPORT: STREPTOCOCCUS PYOGENS ISOLATEDBLOOD

FOR C/S1ST SUB CULTURENO GROWTH AFTER 48HR OF AEROBIC INCUBATIONURINE

C/SNO GROWTH7/8/24ASCITIC FLUID ANALYSISVOL 1MLCOLOUR- YELLOWAPPERENCE:

CLEARTL 250 CELLSDL 80% N, 20% LOTHERS NILASCITIC FLUID SUGAR 123 MG/DLASCITIC

FLUID PROTEIN 0.4G/DLASCITIC FLUID AMYLASE 19.9IU/LASCITIC FLUID LDH 117.1

IU/LSERUM ALBUMIN 1.45 GM/DLASCITIC ALBUMIN 0.14GM/DLSAAG 1.31

8/8/24

BLOOD UREA 50MG/DL

LDL CHOLESTEROL 74

SERUM CREATININE 1.5MG/DL

HB:7.5

TLC: 17,100

PCV:20.7

MCH:34.1

RBC: 2.20

PLATELET COUNT:1.0

CUE:

COLOUR: REDDISH

APPEARANCE: CLEAR

REACTION : ACIDIC

SUGAR: NIL

ALBUMIN: TRACES

BILE SALTS: NIL

BILE PIGMENTS: NIL

PUS CELLS: 4-5 CELLS

EPITHELIAL CELLS: 1-2

RBCS: 8-10

OTHERS: BACTERIALO COLONIES CALCIUM OXALATE TRIPLE PHOSPHATE CRYSTALS SEEN

SERUM OSMOLALITY: 280

SERUM LDH : 155.6

9/8/24

HEMOGRAM:

HB: 8

TLC: 36,000

PCV: 23.2

MCV: 99.6

RBC: 2.33

PLATELET COUNT: 2.14

SERUM CREATININE 2.8

BLOOD UREA: 67

SERUM ELECTROLYTES:

NA: 126

K: 4.7

CL: 98

CA: 1.19

ABG:

PH: 6.7

PCO2: 61.7

PO2: 63.6

USG ABDOMEN PELVIS ON 20/7/24

FINDINGS: ON EXAMINATION 6-7MM CALCULUS IN UPPER POLE OF RIGHT KIDNEY

IMPRESSION:

GRADE I FATTY LIVER

HEPATOMEGALY

SPLEENOMEGALY

RIGHT RENAL CALCULUS

REVIEW USG ON 5/8/24

ON EXAMINATION: FREE FLUID NOTED IN PERIHEPATIC, PERISPLENIC AND INTERBOWEL

FLUID NOTED

IMPRESSION: MODERATE ASCITIS

USG CHEST ON 6/8/24

FINDINGS:

ON EXAMINATION MINIMAL FREE FLUID IN RIGHT PLEURAL SPACE

ON EXAMINATION MINIMAL FREE FLUID IN LEFT PLEURAL SPACE WITH NO AIR

SONOGRAMS IN UNDERLYING LUNGS

NO EVIDENCE OF ANY LUNG COLLAPSE BILATERALLY

IMPRESSION:

BILATERAL MINIMAL PLEURAL EFFUSION RIGHT>LEFT

CONSOLIDATORY CHANGES IN RIGHT LUNG

2D ECHO

EF 64%

MILD TO MODERATE AR: MILD TR: NO PAH, TRIVIAL MR

NO RWMA, NO AS/MS, SCLEROTIC AV

GOOD LV SYSTOLIC FUNTIONS

GRADE I DIASTOLIC DYSFUNTION

REVIEW ON 23/7/24

EF 64%: RVSP: 32MMHG

TRIVIAL TR: NO PAH, TRIVIAL AR

NO RWMA, NO AS/MS, SCLEROTIC AV

GOOD LV SYSTOLIC FUNTIONS

GRADE I DIASTOLIC DYSFUNTION

IVC SIZE 1.0CMS COLLAPSING

REVIEW ON 6/8/24

EF 64%

TRIVIAL AR/TR: NO PAH, NO MR

NO RWMA, MILD LVH

NO AS/MS, SCLEROTIC AV

GOOD LV SYSTOLIC FUNTIONS

GRADE I DIASTOLIC DYSFUNTION

IVC SIZE 0.8CM COLLAPSING

Treatment Given(Enter only Generic Name)

INJ MEROPENEM 1GM IV/BD

TAB METROGYL 400MG PO/TID

INJ PAN 40MG IV /OD

INJ LASIX 40MG IV/TID

INJ HAI SC/TID 4U-4U-4U

TAB HIFINAC P PO/BD

TAB CHYMEROL FORTE PO/TID

SYP CROMAFFINE 15ML PO H/S

TAB MVT PO/OD

TAB VIT C PO/TID

TAB OROFER XT PO/BD

Follow Up

DEATH SUMMARY

59 YEAR OLD MALE RESIDENT OF NALGONDA CAME WITH C/O SWELLING OF RIGHT LEG

AND MULTIPLE BELBS OVER POSTERIOR ASPECT OF RIGHT LEG. ADMITTED UNDER

DEPARTMENT OF GENERAL SURGERY ON 19/7/24 AND MANAGED.

PATIENT WAS SHIFTED TO MEDICAL ICU IN VIEW OF AKI AND DERANGED LFT ON 21/7/24.

PATIENT UNDERWENT EMERGENCY FASCIOTOMY AND DEBRIDEMENT WAS DONE I/V/O

NECROTISING FASCITIS UNDER SA. POST OPERATIVELY PATIENT WAS STARTED ON INJ.

NORAD SUPPORT.

CULTURE AND SENSITIVITY REPORT OF FLUID FROM BLEBS SHOWED STREPTOCOCUS

PYOGENES.

THE PATIENT WAS SHIFTED BACK TO SICU AS AKI RESOLVED AND MAP MAINTAINED

WITHOUT IONOTROPIC SUPPORT.

ON 5/8/24 PATIENT DEVELOPED DYSPNEA AND MODERATE ASCITIS AND BILATERAL

PLUERAL EFFUSION AND REVIEWED BY GENERAL MEDICINE AND ON EXAMINATION

PATIENT HAD BILATERAL CREPTS ON IAA, INTERSCAPULAR AREA, AND WAS ADVICED FOR

FLUID RESTRICTION AND DIURETICS.

PATIENT WAS TRANSFERRED TO GENERAL MEDICINE I/V/O ASCITIS. DIAGNOSTIC TAP WAS

DONE.

IT SHOWED HIGH SAAG LOW PROTEIN AND DIAGNOSED AS CLD ON 8/8/24 10PM. PATIENT

HAD SUDEN ONSET OF TACHYPNEA, TACHYCARDIA AND ON AUSCULTATION BILATERAL

DIFFUSE CREPTS AND BILATERAL RHONCHI PRESENT. STARTED ON NEBULIZATION. ABG

SHOWED PH 7.35, PCO2 25.7MMHG, PO2 60.7MMHG HCO3 13.3 AND WAS PUT ON NON-

INVASIVE VENTILATION TILL 6AM

AT 6.30AM DUE TO FALL IN SATURATION AND TYPE II RESPIRATORY FAILURE PATIENT WAS

INTUBATED WITH ET TUBE '7' AND CONNECTED MECHANICAL VENTILATION ACMV-VC

MODE AND STARTED ON IONOTROPIC SUPPORT

AT 8.30 AM PATIENT HAD SUDDEN BRADYCARDIA AND ABSENT CENTRAL AND PERIPHERAL

PULSES. CPR WAS STARTED AND AFTER 15MIN ROSC ACHIEVED. I/V/O HYPOTENSION

TRIPLE LUMEN WAS PLACED AND TRIPLE IONOTROPI SUPPORT WAS STARTED.

AT 10.30 AM AT PATIENT WAS AGAIN HAD BRADYCARDIA AND DUE TO ABSENT CENTRAL

AND PERIPHERAL PULSES CPR WAS STARTED ACCORDING TO ACLS GUIDELINES

AFTER 30MIN OF CPR PATIENT WAS NOT REVIVED AND DECLARED DEAD AT 11.01AM

IMMEDIATE CAUSE

SEVERE METABOLIC ACIDOSIS WITH TYPE II RESPIRATORY FAILURE

REFRACTORY HYPOTENSION

ANTECEDENT CAUSE

SEPTIC SHOCK WITH MODS

NECROTISING FASCITIS

CHRONIC LIVER DISEASE

ANEMIA OF CHRONIC DISEASE

HFPEF

K/C/O DM-II

K/C/O HYPERTENSION

Death date 9/8/24