2.

 THIS  IS A CASE OF 46 YEAR OLD MALE WITH C/O DRAGGING TYPE OF PAIN OF B/L LOWER LIMBS SINCE EVENING

DECREASED URINEOUTPUT SINCE 15 DAYS

ABDOMINAL DISCOMFORT SINCE 15 DAYS

C/O SWELLING OF BILATERAL LOWER LIMBS SINCE 15 DAYS

HOPI :

PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS AGO AND THEN DEVELOPED SWELLING OF BOTH LOWER LIMBS, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, AND ABDOMINAL DISTENSION SINCE 15 DAYSABDOMINAL DISCOMFORT SINCE 15 DAYSC/O DECREASED URINE OUTPUT SINCE 15 DAYS H/O SEIZURES, 3 EPISODES- ONE IN DEC 2021, JAN 2022, SEP 2022. NOT USED ANY MEDICATION .TONIC SEIZURES, UPROLLING OF EYES +, FROTHING FROM MOUTH +POSTURAL CONFUSION + FOR 15 MINUTES SPONTANEOUS URINATION -SPONTANEOUS DEFECATION -VOMITINGS -LOOSE STOOLS -INCREASED DAYTIME SLEEPINESS SINCE 1 WEEK H/O INCREASED BILIRUBIN LEVELS 1 MONTH BACK HYPERPIGMENTED PATCHES (DIFFUSE) PRESENT OVER THE BODYPAST HISTORYNOT A KNOWN CASE OF HTN, DM, ASTHMA, TB, EPILEPSY.

PERSONAL HISTORY

DIET- MIXED

APPETITE- NORMAL

BOWEL AND BLADDER MOVEMENTS- REGULAR

SLEEP- ADEQUATE 

ADDICTIONS- CHRONIC ALCOHOLIC SINCE 20 YEARS

FAMILY HISTORY-NO SIGNIFICANT FAMILY HISTORY

General examination Done after obtaining consent, in the presence of attendant with adequate exposurePatient is conscious,

coherent, cooperative and well oriented to time, place and personPatient is well nourished and

moderately built

Vitals

Temperature- Afebrile

Blood pressure- 90/70 mmHg

Pulse rate- 82bpm

Respiratory rate- 18 cpm

SPO2- 98%

GRBS- 126 mg%

LOCAL EXAMINATION:

Abdominal examination:

Inspection

Shape of the abdomen- Distended

Umbilicus-everted

Movements of abdominal wall- moves with respiration

Skin is smooth, shiny

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites

Palpation

Inspectory findings are confirmed

Fluid thrill positive

Abdominal girth at the level of umbilicus is maximum

Percussion

Fluid thrill- felt

Auscultation-Bowel sounds are decreased

Cardiovascular system examination:S1 and S2 sounds are heard No murmurs 

Respiratory system examination:Bilateral air entry  , vesicular breath sounds are heard

Central nervous system examination:No focal neurological deficits

DEATH SUMMARYA 44 YEARS OLD MALE, CAME TO CASUALTY WITH COMPLAINTS OF ABDOMINAL DISCOMFORT SINCE 15 DAYS, DECREASED URINE OUTPUT SINCE 15 DAYS AND DRAGGING TYPE OF PAIN OF BILATERAL LOWER LIMBS SINCE EVENINGINITIAL INVESTIGATIONS WERE DONE AFTER CLINICAL EXAMINATION OF THE PATIENT AND PATIENT WAS DIAGNOSED WITH ACUTE DECOMPENSATED LIVER DISEASE, SECONDARY TO ALCOHOL GRADE 2 HEPATIC ENCEPHALOPATHY WITH AKI SECONDARY TO RIGHT LOWER LIMB CELLULITIS, AND MANAGED SYMPTOMATICALLY AND RYLES TUBE WAS PLACED AND DIAGNOSTIC ASCITIC TAP WAS DONEAT 2:00 PM, HIS BP WAS NOT RECORDABLE AND PATIENT WAS STARTED ON IONOTROPES TO MAINTAIN BP, BUT STILL HIS BP WASN'T MAINTAINED EVEN ON TRIPLE IONOTROPIC SUPPORT AND AROUND 5:00 PM, ABG WAS DONE SHOWING SEVERE METABOLIC ACIDOSIS, AND BICARBONATE CORRECTION WAS GIVEN, BUT STILL ACIDOSIS IS PERSISTING AND AROUND 9:00 PM, PATIENT HAS BEEN INTUBATED IN VIEW OF FALLING GCS AND FALLING SATURATIONSPOST INTUBATION VITALS: HIS BP IS NOT RECORDABLE AND HIS PULSE RATE IS AROUND 120 BPMPATIENT GRADUALLY DEVELOPED BRADYCARDIA AND SUDDENLY WENT INTO CARDIAC ARREST, FOLLOWED BY WHICH CPR WAS DONE FOR 30 MINUTES, ACCORDING TO AHA GUIDELINES, FOLLOWED BY WHICH PATIENT COULDNOT BE REVIVED AND DECLARED DEAD AT 10:25 PM ON 29/10/22 AS A FLAT LINE WAS OBSERVED ON ECGCAUSE OF DEATHIMMEDIATE CAUSE OF DEATHREFRACTORY HYPOTENSION SECONDARY TO SEPSISANTECEDENT CAUSE OF DEATHSEPSIS WITH MODS, RIGHT LOWER LIMB CELLULITISACUTE DECOMPENSATED CHRONIC LIVER DISEASE, ?ESOPHAGEAL VARICEAL BLEEDINGAKI SECONDARY TO SEPSIS WITH GRADE 2 HEPATIC ENCEPHALOPATHY 

Investigation 

1. CHEST XRAY PA VIEW- NO ABNORMALITY DETECTED 

2. ECG- NO ABNORMALITY DETECTED

 3.USG- MILD SPLENOMEGALY GROSS ASCITES RIGHT RENAL CALCULUS GB SLUDGE GRADE 1 FATTY LIVER ,NO AS/MS IAS- INTACT EF- 62 RVSP- 45+10 = 55 MMHG GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION NO PE IVC SIZE (1.68 CMS) DILATED DILATED L.A/R.A/R.V/IVC.

Diagnosis: ACUTE DECOMPENSATED LIVER DISEASE SECONDARY TO ALCOHOL WITH GRADE 2 HEPATIC ENCEPHALOPATHY

Treatment Given(Enter only Generic Name)

TREATMENT29/10/22 (8:00 AM)

1. RT FEEDS WITH 100 ML MILK + 200 ML FREE WATER 2ND 

2. TAB. PENTOXYPHYLLINE 400 MG/PO/BD

3. TAB. LASIX 40 MG/PO/BD

4. TAB. SPIRANOLACTONE 25 MG/PO/OD

5. SYP. LACTULOSE 30 ML/PO H/S

6. TAB. UDILIV 300 MG/PO/BD

7. TAB. RIFAGUT 550 MG/PO/BD

8. INJ. CEFOTAXIM 2GM/IV/BD

29/10/22 (2:00 PM)

1. STARTED ON IONOTROPESINJ. NORADRENALINE

2 AMP IN 46 ML NS @ 8 ML/HR INCREASE/DECREASE TO MAINTAIN MAP OF 65 MMHGLATER AROUND 4:00 PM BP HASN'T PICKED UP, EVEN AFTER MAXIMUM OF NORADRENALINETHEN VASOPRESSIN HAVE BEEN STARTED

29/10/22 (6:00PM)

1. PLAN FOR ELECTIVE INTUBATION IN V/O LOW GCS

2. INJ. NORADRENALINE 2 AMPLES + 46 ML NS @ 24 ML/HR

3. INJ. VASOPRESSINE 1 AMPOULE IN + 49 ML NS @ 2 ML/HR

4. INJ. DOBUTAMINE 25 MCG (5M) + 45 ML NS @ 3.6 ML/HR

5. INJ. SODIUM BICARBONATE 100 MEQ STAT IV

6. INJ. 100 MEQ OF SODIUM BICARB IN 100 ML NS OVER 1 HOUR7. INJ. SODABICARBS 25 MEQ IN 50 ML NS OVER 30 MIN

29/10/22 (9:00 PM)PATIENT WAS INTUBATED WITH ET 7.5 AFTER PASSING BUJIE POSITION WAS CONFIRMED WITH 5 POINT PROFILE AUSCULTATIONPRE OXYGENATION FOR 3 MINUTES DONEPRE INTUBATION MEDICATIONINJ. MIDAZ 3 CC IV GIVENINJ. ATRACURIUM 1CC IV GIVENINJ. ONDEN 4 CC IV GIVENPOST INTUBATION VITALSHR- 120 BPMBP- NOT RECORDABLE

CVS- S1, S2 +R/S- B/L AIR ENTRY PRESENT 

RIGHT INFRA AXILLARY CREPTS +AFTER 20 MINUTES OF INTUBATIONTHERE WAS A SUDDEN FALL OF HEART RATEHR- 42 BPMSPO2- 34%PATIENT WAS ARRESTED IN VIEW OF WHICH CPR WAS INITIATED29/10/22 (9:55 PM)DUE TO SUDDEN FALL IN HEART RATE AND SATURATION SPO2 35 MM OF HG AND SUDDEN CARIDAC ARREST, CPR WAS INITIATED ACCORDING TO AHA GUIDE LINESBP NOT RECORDABLE, PULSE NOT RECORDABLE, INJ. ADRENALINE 1CC IV GIVEN, CPR INITIATED29/10/22 (10:00 PM)BP &PR NOT RECORDABLEINJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED29/10/22 (10:05 PM)BP &PR NOT RECORDABLEINJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED29/10/22 (10:10 PM)BP &PR NOT RECORDABLEINJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED29/10/22 (10:15 PM)BP &PR NOT RECORDABLEINJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED29/10/22 (10:20 PM)BP &PR NOT RECORDABLEINJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED29/10/22 (10:25 PM)BP &PR NOT RECORDABLEDESPITE OF CONTINUOUS RESUSCITATIVE EFFORTS PATIENT COULD NOT BE REVIVED AND DECLARED DEATH AT 10:25 PM ON 29/10/22.