11.

 Case History and Clinical Findings

71 YEAR OLD MALE WITH CHIEF COMPLAINTS OF

C/O GENERALISED BODY SWELLING SINCE 1 WEEK

C/O SHORTNESS OF BREATH SINCE 2DAYS

C/O DECREASED URINE OUTPUT SINCE MORNING

HISTORY OF PRESENT ILLNESS :- PATIENT WAS APPARENTLY ALRIGHT 1 YEAR BACK THEN HE HAD LEFT HEMIPARESIS FOR

WHICH HE USED HERBAL MEDICATION AND THEN RESOLVED AFTER 3DAYS (POWER

IMPROVED ).

6 MONTHS BACK HE HAD PEDAL OEDEMA WHICH IS PITTING TYPE TILL KNEE AGGREVATED

ON SLEEPING (INTERMITTENT ) WHICH RELIEVED ON WALKING

C/O COUGH SINCE 1 MONTH, PRODUCTIVE IN NATURE,SCANTY SPUTUM NON

BLOODSTAINED, INTERMITTENT COUGH WHICH RELIEVED AFTER TAKING MEDICATION.

C/O PEDAL EDEMA SINCE 1 WEEK, FROM LOWER LIMBS AND GRADUALLY PROGRESSED

TO ENTIRE BODY

C/O SHORTNESS OF BREATH SINCE 2DAYS. NYHA GRADE II PROGRESSED TO GRADE III

FROM 1 WEEK . SOB EVEN AT REST

ORTHOPNEA PRESENT

PND,LOSS OF APPETITE,WEIGHT LOSS ,CHEST PAIN ,PALPITATIONS WERE ABSENT .

PAST HISOTRY

NOT A KNOWN CASE OF HYPERTENSION, DIABETES MELLITUS,TUBERCULOSIS,

BRONCHIAL ASTHMA, EPILEPSY,CORONARY HEART DISEASE.

H/O OLD CVA WITH LEFT HEMIPARESIS 1 YR BACK .

VITALS AT PRESENTATION

BP-140/70MMHG

PR-150BPM

RR-20CPM

GRBS-176MG/DL

SPO2-98 % ON RA

CNS - PATIENT WAS DROWSY BUT AROUSABLE ; E3 V4M5

MENINGEAL SIGNS WERE ABSENT

TONE- NORMAL IN BILATERAL UPPER AND LOWER LIMBS

POWER R L

U/L 5/5 5/5

L/L 5/5 5/5

REFLEXES B T S K A P

R + + + + + flexion

L + + + + + flexion CVS- S1S2 HEARD; NO MURMURS

RESPIRATORY- BILATERAL AIR ENTRY PRESENT ; NO ADDED SOUNDS

PERABDMEN- SOFT ; DISTENDED; NO TENDERNESS PRESENT

BOWEL SOUNDS HEARD

COURSE IN THE HOSPITAL

A 70 YEAR OLD MALE CAME TO THE CASUALTY WITH COMPLAINTS OF GENERALISED BODY

SWELLING SINCE 1 WEEK, SHORTNESS OR BREATH SINCE 2DAYS AND DECREASED URINE

OUTPUT SINCE MORNING, WAS DROWSY AT THE TIME OF ADMISSION AND INITIAL

EVALUATION WAS DONE TO RULE OUT THE CAUSE OF FLUID OVERLOAD AND ON FURTHER

INVESTIGATIONS WAS FOUND TO BE HAVING DECOMPENSATED CHRONIC LIVER DISEASE

WITH HEPATIC ENCEPHALOPATHY WITH A CHEST X-RAY SHOWING LEFT SIDED PLEURAL

EFFUSION WITH USG ABDOMEN SHOWING MODERATE ASCITES.

AS THE PATIENT IS DROWSY AND DIDN’T PASS STOOLS, ENEMA WAS PLACED AND THE

PATIENT PASSED STOOLS AND USG CHEST WAS DONE AND SHOWED MODERATE

EFFUSION WITH INTERNAL ECHOES NOTED IN LEFT PLEURAL SPACE WITH COLLAPSE OF

UNDERLYING LUNG SEGMENT AND MILD PLEURAL EFFUSION WITH THICK SEPTATIONS

NOTED IN RIGHT PLEURAL SPACE

AND AS THE PATIENT IS DROWSY, RYLE’S TUBE WAS PLACED AND FEEDS WAS GIVEN AND

IN VIEW OF CHRONIC DECOMPENSATED LIVER DISEASE,

INJ. VITAMIN K WAS GIVEN AS A PROPHYLACTIC MEASURE TO PREVENT BLEEDING AND AS

HE IS HAVING HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF60%)PRELOAD

REDUCING AGENTS WERE GIVEN BY MONITORING SERUM ELECTROLYTES VALUES AND

OSMOTIC LAXATIVES WERE ADDED TO PASS STOOLS (3TIMES PER DAY)

ON DAY 3 OF ADMISSION HE SUDDENLY DEVELOPED IRREGULAR HEART RATE AND THE

ECG WAS SHOWING IRREGULARLY IRREGULAR HEART RATE AND ABSENT P WAVES AND

RATE CONTROLLING AGENTS AND RHYTHM CONTROLLING DRUGS WERE STARTED WITH

INJ. AMIODARONE INFUSION STARTED AT 150 MG/IV STAT FOLLOWED BY 600 MG IN 50 ML

NS FOR 6 HRS @ 5 ML /HR . AS THE PERIPHERAL ACCESS COULDN’T BE FOUND, THEN

CENTRAL CANNULA WAS PLACED IN THE RIGHT FEMORAL VEIN.

PROCEDURE WAS UNEVENTFUL.ABG AND ECG MONITORING WERE DONE 6TH HOURLY AS

THE PATIENT IS TACHYPNIC AS THE SATURATION OF OXYGEN WAS NOT MAINTAINING ON

ROOM AIR. ABG MONITORED 6THOURLY AND ECG WAS DONE TO LOOK FOR THE HEART

RATE RHYTHM AT 8:00AM IN THE MORNING (27/01/23) PATIENT HAD SUDDEN BLEEDING FROM NASAL AND

ORAL CAVITY . HE WAS IN A DROWSY STATE AND SUDDENLY DEVELOPED BRADYCARDIA

AND THE CENTRAL AND PERIPHERAL PULSES COULDN’T BE FELT AND THE PATIENT WAS

INTUBATED WITH ET TUBE NO.7 M, AFTER DIRECT VISUALISING THE VOCAL CORDS WITH

LARYNGOSCOPE, RAPID SEQUENCE INTUBATION WAS DONE AND THE

CARDIOPULMONARY RESUSCITATION WAS INITIATED ACCORDING TO THE AMERICAN

HEART ASSOCIATION 2020 GUIDELINES AND CPR WAS CONTINUED FOR 30MINS. DESPITE

OF ALL RESUSCITATIVE EFFORTS PATIENT COULDN’T BE RECOVERED AND DECLARED

DEAD AT 9:12 AM ON 27/1/23

IMMEDIATE CAUSE OF DEATH

• PAROXYSMAL ATRIAL FIBRILLATION (SECONDARY TO HEART FAILURE)

• CHRONIC DECOMPENSATED LIVER DISEASE WITH HEPATIC ENCEPHALOPATHY, LEFT

PLEURAL EFFUSION AND ASCITES

• HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF 60%)

• PRE RENAL ACUTE KIDNEY INJURY

ANTECEDENT CAUSE OF DEATH

-H/O CEREBRAL VASCULAR ACCIDENT WITH LEFT HEMIPARESIS (1 YEAR BACK)

Investigation

HB-13.9GM/DL

TLC-11,650 CELLS/CUMM

PLT-1.50LAKHS/CUMM

26/01/23

USG CHEST :- E/O MODERATE RFFUSION WITH INTERNAL ECHIES NOTED IN THE LEFT

PLEURAL SPACE, WITH COLLAPSE OF UNDERLYING LUNG SEGMENT

E/O MILD PLEURAL EFFUSION WITH THICK SEPTATIONS NOTED IN THE RIGHT PLEURAL

SPACE

USG ABDOMEN 26/01/23

RAISED ECHOGENICITY OF BOTH KIDNEYS

MODERATE ASCITES

GRADE I FATTY LIVER

2DECHO 25/01/23

NO RWMA. MILD LVH(1.23CMS) MODERATE TR AND PAH (52 + 10 62MMHG)

MILD AR/MR

SCLEROTIC AV, NO AS/MS

EF=60 GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION

MILD PLEURAL EFFUSION

IVC SIZE (1.83CMS) DILATED NON COLLAPSING

DILATED R.A/R.V/L.A/IVC

Diagnosis 1) PAROXYSMAL ATRIAL FIBRILLATION ( SECONDARY TO HEART FAILURE) 2) CHRONIC DECOMPENSATED LIVER DISEASE WITH HEPATIC GRADE 1 ENCEPHALOPATHY , LEFT PLEURAL EFFUSION AND ASCITES 3) HEART FAILURE WITH PRESERVED EJECTION FRACTION ( EF60%) 4) PRENAL ACUTE KIDNEY INJURY 5)H/O CEREBROVASCULAR ACCIDENT WITH LEFT HEMIPARESIS ( 1 YEAR BACK)

Treatment Given(Enter only Generic Name)

INJ. LASIX 40 MG IV BD

TAB RIFAGUT 550MG PO BD

TAB UDILIV 300MG PO BD

TAB ECOSPIRIN AV 75/10 PO BD

SYP LACTULOSE 30ML PO HS

INJ. VITAMIN K IV OD

INJ. ADRENALINE 1MG