Case 41. 80 female in unresponsive state since 12 days

Doa 8/8/24

Expired on 13/8/24

Diagnosis

SPECTIC ENCEPHALOPATHY

SEPTIC SHOCK SECONDARY TO NECROTISING FASICITISWITH RIGHT LL CELLULITIS

TYPE 1 RESPIRATORY FAILURE

ASPIRATION PNEUMONIA

K/C/O DMT2 AND HTN SINCE 5 YRS

K/C/O CAD SINCE 3 YRS

Case History and Clinical Findings

PATIENT CAME TO CASUALTY WITH C/O UNRESPONSIVENESS SINCE 12 DAYS

HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIC 12 DAYS BACK SHE THEN HAd MULTIPLE

EPISODES OF vomitings AND LOOSE STOOLS FOR 2 DAYSAND SUBSIDED.

H.O PASSAGE OF BLACK COLORED STOOLS

THEN SHE BECAME UNRESPONSIVE AND WAS ADMITTED IN A NEARBY HOSPITAL

DURING HER HOSPITAL STAY SHE DEVELOPED DISCOLORATION OF RIGHT LL WITH

BLISTERS AND SWELLING OF LEFT LL AND UL

H/O FLEXION DEFORMITY OF RIGHT ELOBOW JOINT

NO H/O FEVER,SOB,CHEST PAIN

PATINET IS A K/C/O DM,HTMN SINCE 5 YEARS ON MEDICATION

N/K/C/O CVA,THYROID,BRONCHIAL ASTHMA

H/O CAD SINCE 3 YEARS ON ROSUVAS GOLD 75/75/10

NO SIGNIFICANT FAMILY HISTORY

DIET- MIXED

APPETITE- NORMAL

SLEEP- ADEQUATE

BOWEL- REGULAR

MICTURITION - NORMAL

ADDICTIONS: TOBACCO SNUFF

PATIENT HAS ATTAINED MENOPAUSE

GENERAL EXAMINATION:

NO PALLOR , ICTERUS, CYANOSIS, CLUBBING ,LYMPHADENOPATHY

VITALS:

TEMP: 97.5 F

PR: 110 BPM

RR: 30 CPM

BP: NR

SPO2: 65% ON RA 82 WITH FULL FLOW O2 FOR 30-45 MIN(100%FIO2 16L O2)

GRBS: 177 MG%

SYSTEMIC EXAMINATION-

CVS: S1 S2 HEARD, NO THRILLS, NO MURMERS

RESP: BAE+, NVBS HEARD

PER ABDOMEN: SOFT ,NON TENDER

CNS: SPEECH NO RESPONSIVE

POWER CANNOT BE ELICITED

E2V1M1

REFLEXES -ALL ABSENT

CEREBRAL SIGNS-NOT ELICITED

GENERAL SURGERY REFFERAL WAS DONE I/V/O CELLULITIS:

DIAGNOSIOS:SEPTIC SHOCK SECONDARY TO NECROTISING FASCITIS

ADVICED:MGSO4 DRESSING B/L UPPER AND LOWER LIMBS

TERPENTINE OIL WITH DEBRIDEMENT OF RIGHT LL

SURGICAL PROFILE

Investigation

RFT 08-08-2024 12:54:PMUREA 204 mg/dl 50-17 mg/dlUREA 213 mg/dl 50-17 mg/dlCREATININE

2.1 mg/dl 1.2-0.6 mg/dlCREATININE 2.2 mg/dl 1.2-0.6 mg/dlURIC ACID 8.1 mmol/L 6-2.6

mmol/LURIC ACID 8.1 mmol/L 6-2.6 mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dlCALCIUM 9.8 mg/dl

10.2-8.6 mg/dlPHOSPHOROUS 5.1 mg/dl 4.5-2.5 mg/dlPHOSPHOROUS 5.1 mg/dl 4.5-2.5

mg/dlSODIUM 151 mmol/L 145-136 mmol/LPOTASSIUM 4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

114 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 08-08-2024 12:54:PMTotal Bilurubin 1.90 mg/dl 1-0 mg/dlDirect

Bilurubin 0.26 mg/dl 0.2-0.0 mg/dlSGOT(AST) 139 IU/L 31-0 IU/LSGPT(ALT) 145 IU/L 34-0

IU/LALKALINE PHOSPHATASE 147 IU/L 141-53 IU/LTOTAL PROTEINS 4.6 gm/dl 8.3-6.4

gm/dlALBUMIN 1.52 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.49HBsAg-RAPID 08-08-2024 12:54:PM

Negative

Anti HCV Antibodies - RAPID 08-08-2024 12:54:PM Non ReactiveABG 08-08-2024 12:55:PMPH

7.34PCO2 20.1PO2 44.4HCO3 10.8St.HCO3 13.4BEB -13.6BEecf -13.9TCO2 23.6O2 Sat 70.6O2

Count 6.8

ABG 08-08-2024 12:56:PMPH 7.32PCO2 15.0PO2 96.4HCO3 7.6St.HCO3 10.8BEB -17.5BEecf -

17.6TCO2 17.0O2 Sat 95.6O2 Count 7.7ABG 08-08-2024 05:42:PMPH 7.290PCO2 28.4PO2

384HCO3 13.2St.HCO3 15.1BEB -11.8BEecf -12.0TCO2 28.3O2 Sat 99.3O2 Count 14.2

ABG 08-08-2024 10:25:PMPH 7.27PCO2 29.6PO2 377HCO3 13.4St.HCO3 14.9BEB -11.9BEecf -

12.0TCO2 29.5O2 Sat 99.3O2 Count 11.1ABG 09-08-2024 12:08:AMPH 7.26PCO2 27.8PO2

112HCO3 12.3St.HCO3 13.8BEB -13.3BEecf -13.3TCO2 29.4O2 Sat 97.1O2 Count 7.9

RFT 09-08-2024 12:08:AMUREA 222 mg/dl 50-17 mg/dlCREATININE 2.2 mg/dl 1.2-0.6 mg/dlURIC

ACID 7.8 mmol/L 6-2.6 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 6.5 mg/dl 4.5-

2.5 mg/dlSODIUM 150 mmol/L 145-136 mmol/LPOTASSIUM 4.4 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

104 mmol/L 98-107 mmol/LABG 09-08-2024 04:11:PMPH 7.17PCO2 41.8PO2 104HCO3

14.6St.HCO3 14.4BEB -12.6BEecf -12.3TCO2 32.8O2 Sat 96.7O2 Count 10.9

ABG 09-08-2024 05:45:PMPH 7.16PCO2 37.3PO2 47.9HCO3 12.8St.HCO3 12.9BEB -14.2BEecf -

14.1TCO2 29.7O2 Sat 70.4O2 Count 5.5ABG 09-08-2024 11:56:PMPH 7.19PCO2 8.8PO2

57.9HCO3 3.3St.HCO3 7.2BEB -24.4BEecf -24.4TCO2 7.1O2 Sat 74.9O2 Count 10.9

RFT 09-08-2024 11:56:PMUREA 222 mg/dl 50-17 mg/dlCREATININE 2.3 mg/dl 1.2-0.6 mg/dlURIC

ACID 7.4 mmol/L 6-2.6 mmol/LCALCIUM 10.1 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 7.3 mg/dl 4.5-

2.5 mg/dlSODIUM 151 mmol/L 145-136 mmol/LPOTASSIUM 4.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

106 mmol/L 98-107 mmol/LABG 10-08-2024 08:07:AMPH 7.18PCO2 36.5PO2 105HCO3

13.2St.HCO3 13.7BEB -13.7BEecf -13.5TCO2 29.7O2 Sat 97.0O2 Count 9.9

ABG 11-08-2024 12:21:AMPH 6.95PCO2 54.4PO2 44.9HCO3 11.5St.HCO3 9.4BEB -20.6BEecf -

18.3TCO2 26.8O2 Sat 69.6O2 Count 11.1LIVER FUNCTION TEST (LFT) 11-08-2024 12:21:AMTotal

Bilurubin 0.73 mg/dl 1-0 mg/dlDirect Bilurubin 0.18 mg/dl 0.2-0.0 mg/dlSGOT(AST) 24 IU/L 31-0

IU/LSGPT(ALT) 48 IU/L 34-0 IU/LALKALINE PHOSPHATASE 121 IU/L 141-53 IU/LTOTAL

PROTEINS 4.7 gm/dl 8.3-6.4 gm/dlALBUMIN 1.85 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.65

RFT 11-08-2024 12:21:AMUREA 251 mg/dl 50-17 mg/dlCREATININE 2.5 mg/dl 1.2-0.6 mg/dlURIC

ACID 6.9 mmol/L 6-2.6 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 7.9 mg/dl 4.5-

2.5 mg/dlSODIUM 149 mmol/L 145-136 mmol/LPOTASSIUM 4.6 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

106 mmol/L 98-107 mmol/L

2D ECHO REPORT:TACHYCARDIA DURING SYSTOLE

VPCS +

NO RWMA

MODERATE TR+WITH MILD PAH

MILD AR+

TRIVIAL MR+MAC+

SCLEROTIC AV NO AS/MS IAS-ANEYRYSM

EF 60%

GOOD LV SYSTOLI8C FUNCTION

GRADE 1 DIASTOLIC DYSFUNCTION

IVC SIXE 0.7CMS COLLAPSING

ECG(11/8/24):COMPLETE HERAT BLOCK

USG ABDOMEN:NO SONOLOGICAL ABNORMALITY DETECTED

Treatment Given(Enter only Generic Name)

RT FEEDS 200ML WATER 2 ND HRLY

200 MILK WITH PROTEIN POWDER 4 HRLY

IV FLUIDS NS'150L/HR

INJ NORADRENALINE IV INFUSION AT 15 ML/HR

INJ DOBUTAMINE INFUSION AT 4 ML/HR

INJ VASOPRESSINE INFUSION AT 2 UNITS/HR

INJ MIDAZ +FENTANYL INFUSION AT 8 ML/HR

INJ MEROPENAM 500MG IV/BD

INJ CLINDAMYCIN 600MG IV/BD

INJ PAN 40 MG IV/OD

INJ NEOMOL 1 GM IV SOS

INJ HAI SC TID ACC TO GRBS

INJ HUMAN ALBUMIN 20% IV OVER 45 MIN

INJ 25D INFUSION AT 15 ML/HR

REGULAR DRESSING

Advice at Discharge

REFFER TO HIGHER CENTRE NOTES:A PATIENT OF AGE 80 YRS FEMALE CAME TO

CASUALTY WITH COMPALINTS OF UNMRESOPNSIVE NESS SINCE 12 DAYS.SHE

DEVELOPED CELLULITIS OF ALL 4 LIMBS IN OYTSIDE HOSPITAL AND CAME WITHMYIASIS

OF RIGHT LL AND DIAGNOISED AS TYPE 1 RESPIRATORY FAILURE,ASPIRATION

PNEUMONIA,K/C/O DMT2,HTN SINCE 5 YRS WITH K/C//O CAD SINCE 3 YRS AND HAS BEING

INTUBATED I.V.O FALL IN SATURATIONS AND LOW GCS BP NON RECORDABLE TRIPLE

INOTROPIC SUPPORT WAS STARTED .INSPITE OF TRIPLE INOTROPIS SUPPRT BP WAS LOW

.THERE WA SINCREASED UREA,LOW URINE OUT PUT FROM DAY 1.THERE WAS

CONTINUOUS HYPOGLYCEMIA FROM TODAY MRNG TODAYS ECG SHOWED COMPLETE

HEART BLOCK DISCUSSED WITH CARDIOLOGIST DR.MAHHRANDH.

PATIENT WAS REFFERED TO HIGHER CENTRE I/V/O PACE MAKER IMPLANTATION

DOCTOR HOSPITAL STAFFA ND MANAGEMENT ARE NOT RESPONSIBLE FOR ANY

UNTOWARD EVENTS OUTSIDE THE HOSPITAL

Follow up patient expired in outseide hospital after CAG done