6.

 Case History and Clinical Findings

CHIEF COMPLAINTS:

A 50 YR OLD MALE PATIENT C/O RIGHT SHOULDER PAIN AND RIGHT UPPER LIMB SWELLING SINCE 15 DAYS

C/O GENERALIZED WEAKNESS SINCE 10 DAYS

C/O GENERALIZED SWELLING OF THE BODY SINCE 3 DAYS

C/O SHORTNESS OF BREATH SINCE 3 DAYS

C/O DECREASED URINE OUTPUT SINCE 2 DAYS

C/O ALTERED SENSORIUM SINCE 1 DAY

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 2 WEEKS AGO THEN HE DEVELOPED

TRAUMA TO THE RIGHT HAND ( WHILE OPENING SHUTTER) AND HAD INJURY TO THE

SHOULDER. SLOWLY HE DEVELOPED SWELLING OF THE RIGHT UPPER LIMB GIDDINESS

SINCE 1 WEEK. GENERALIZED SWELLING OF THE BODY SINCE 3 DAYS ALTERED

SENSORIUM SINCE 1 DAY.

H/O UNCONTROLLED SUGARS 4 DAYS BACK. DECREASED URINE OUTPUT SINCE 3 DAYS

SHORTNESS OF BREATH SINCE 3 DAYS, INSIDIOUS IN ONSET AND GRADUALLY

PROGRESSIVE, GREDE 2 TO 4. ORTHOPNEA PRESENT.

PAST ILLNESS:

K/C/O DM TYPE 2 SINCE 18 YEARS ON IRREGULAR MEDICATION.

H/O ADMISSION FOR ? CHRONIC LIVER DISEASE 15 YRS AGO

ON EXAMINATION :

PATIENT IS DROWSY,BUT AROUSABLE

VITALS

TEMP-AFEBRILE

PR-96/MIN

BP-80/60 MM HG

RR-30/MIN

SPO2-90 ON RA

DEATH SUMMARY :

50 YEAR OLD MALE DAILY WAGE LABOURER K/C/O TYPE 2 DM SINCE 18 YEARS

PRESENTED WITH COMPLAINTS OF RIGHT SHOULDER PAIN AND SWELLING SINCE 15 DAYS

, GENERALISED WEAKNESS SINCE 10 DAYS , SHORTNESS OF BREATH SINCE 3 DAYS ,

ALTERED SENSORIUM SINCE 2 DAYS , DECREASED URINE OUTPUT SINCE 3 DAYS VITALS

AT THE TIME OF ADMISSION BP 70/40 MM HG, PR 98/ MIN, SPO2 90 % ON RA, 96 % ON 5 L

O2, TEMP 98.8 DEGREE F. PATIENT WAS PROVISIONALLY DIAGNOSED AS ALTERED

SENSORIUM SECONDARY TO ?UREMIC ENCEPHALOPATHY ?SEPTIC ENCEPHALOPATHY

WITH SEPTIC SHOCK WITH SEVERE METABOLIC ACIDOSIS WITH RIGHT UPPER LIMB

LYMPHEDEMA/ CELLULITIS WITH BURSITIS. PATIENT WAS STARTED ON IV FLUIDS,

ADEQUATE FLUID RESUSCITATION WAS DON. INJ NORAD INFUSION WAS STARTED. INJ

SODIUM BICARBONATE 50 MeQ SLOW IV FOLLOWED BY INJ SODA BICARBONATE 100 MeQ

IN 100ML NS. INVESTIGATIONS REVEALED HB:9.8 GM/DL, TLC - 5400/CUMM, N/L/E/M/B:

92/3/0/5/0, PCV: 28.3, PLATELETS: 2.7 X 10*5/CUMM, CREATININE: 40 mg/dl, BLOOD UREA: 213

mg/dl, SERUM SODIUM:124 MEQ/L, SERUM POTASSIUM: 5.4 MEQ/L, CHLORIDE: 95 MEQ/L,

ABG PH- 7.14, PCO2- 17.9 PO2- 85.1 HCO3- 5.9 02 SATURATION- 92.5. AT 9PM. DURING

DIALYSIS PATIENT HAS FALLING BLOOD PRESSURE. INJ DOBUTAMINE AND VASOPRESSIN

WAS STARTED. 1 HOUR IN VIEW OF DERANGED RFT PATIENT ATTENDER HAVE BEEN

EXPLAINED ABOUT THE NEED FOR CENTRAL LINE AND HO. AFTER TAKING CONSENT FROM

PATIENT ATTENDERS RIGHT FEMORAL CENTRAL LINE WAS PLACED. PATIENT WAS TAKEN

UP FOR DIALYSIS AFTER DIALYSIS PATIENT HAS SUDDEN FALL OF SATURATION AND

UNRESPONSIVE CRASH INTUBATION WAS DONE WITH 7.0 MMET TUBE AND WAS

CONNECTED TO ACMV-VC MODE. IN VIEW OF SEVERE SEPSIS PATIENT WAS STARTED ON

INJ MEROPENAM AND PIPTAZ. AT AROUND 6:40 AM PATIENT HAD SUDDEN BRADYCARDIA

AMD DESATURATION. IMMEDIATE CPR WAS STARTED AS PER THE LATEST ACLS

GUIDELINE AND CONTINUED FOR 30 MINUTES. DESPITE THE ABOVE RESUSCITATION

EFFORTS THE PATIENT CANNOT BE REVIVED AND DECLARED DEAD AT 7:12 AM AFTER THE

ECG SHOWED FLAT LINE.

IMMEDIATE CAUSE OF DEATH:

1. SEVERE METABOLIC ACIDOSIS

2. SEPTIC SHOCK WITH REFRACTORY HYPOTENSION

3. ALTERED SENSORIUM SECONDARY TO ?UREMIC ENCEPHALOPATHY ?SEPTIC

ENCEPHALOPATHY.

ANTECEDENT CAUSE OF DEATH:

1. PRE RENAL AKI ON CKD

2. RIGHT UPPER LIMB LYMPHEDEMA/ CELLULITIS

3. TYPE 2 DM

Investigation

HEMOGRAM

HB 9.8 GM /DL

TLC 54,000 CELLS/CUMM

N/L/E/M/B 92/3/0/5/0

PCV 28.3

PLT 2.7 LAKHS/CUMM

RFT

BLOOD UREA 213 MG/DL

SERUM CREATININE 40 MG/DL

SERUM SODIUM 124 MEQ/L /DL

SEUM POTASSIUM 5.4 MEQ/L

SERUM CL 95 MEQ/L

FBS 87 MG/DL

CUE

ALBUMIN 1+

SUGARS NIL

PUS CELLS 4-6 /HPF

EPITHELIAL CELLS 3-4 /HPF

RBC S 6-8 CELLS /HPF

LFT

TB 3.07 MG/DL

DIRECT BILIRUBIN 2.72 MG/DL

SGOT 63 IU/L

SGPT 27 IU/L

ALP 218 IU/L

TOTAL PROTEIN 5.5 GM/DL

ALBUMIN 2.12 GM/DL

A/G RATIO 0.6

ABG

PH 7.14

PCO2 17.9 MM HG

PO2 85.1 MMHG

HCO3 5.9 MMOL/L

RIGHT UPPER LIMB ARTERIAL DOPPLER DONE ON 24/10/23

IMPRESSION:

DECREASED FLOW IN RADIAL AND ULNAR ARTERIES

DIFFUSE SUBCUTANEOUS EDEMA FROM SHOULDER TO HAND

USG ABDOMEN AND PELVIS ON 24/10/23

RT KIDNEY :10.4X5.1CMS

LT KIDNEY: 10.2X4.8CMS

IMPRESSION:

MILD HEPATOSPLEENOMEGALY

HYPERECHOIC FOCI IN GALLBLADDER

GALLBLADDER POLY(N) CALCULI

Diagnosis ALTERED SENSORIUM SECONDARY TO ? UREMIC ENCEPHALOPATHY / ? SEPTIC ENCEPHALOPATHY AKI ON CKD SEPTIC SHOCK WITH MODS SECONDARY TO ? RIGHT UPPER LIMB CELLULITIS ? LYMPHEDEMA WITH SEVERE METABOLIC ACIDOSIS WITH DM TYPE 2

Treatment Given(Enter only Generic Name)

1.IV FLUIDS NS @UO+30ML/HR

2.INJ.SODIUM BICARBONATE 50MEQ SLOW IV OVER 1 NS

3.INJ.SODIUM BICARBONATE 50MEQ 100ML NS OVER 1HR

4.NEBULIZATION WITH DUOLIN AND BUDECORTP/N STAT

5.INJ. NORAD 4ML IN 46ML NS (INCREASE OR DECREASE AS PER MAP >65MMHG)

6.INJ.PIPTAZ 4.5GM IV/STAT

FOLLOWED BY INJ.PIPTAZ 2.25GM IV/TID

7.INJ.CLINDAMYCIN 600MG IV/BD

8. INJ. MEROPENEM 1 GM IV STAT F/B 500MG IV BD

8.INJ. PAN 40MG IV/OD

9. INJ DOBUTAMINE 1 AMP IN 45 ML NS @ 4ML/HR TO INCREASE OR DECREASE AS PER

MAP GREATER THAN 65 MMHG.

10. INJ VASOPRESSIN 1 AMP IN 39 ML NS @ 2.4 ML/HR TO INCREASE OR DECREASE TO

MAINTAIN MAP GREATER THAN 65MMHG.