01-01-2025
https://youtu.be/T5C3nPfyP6E?feature=shared
EMR SUMMARY
He died yesterday.
Was their blood aspirated in the ryles tube inserted for this patient on Saturday?👇
Age/Gender : 45 Years/Male
Address :
Discharge Type: Expired
Admission Date: 10/12/2024 06:18 PM Death Date: 30/12/2024 07:50 PM
Diagnosis
SEPTIC SHOCK SECONDARY TO SPONTANEOUS BACTERIAL PERITONITIS DECOMPENSATED CHRONIC LIVER DISEASE WITH OESOPHAGEAL VARICES BLEEDING HEPATIC ENCEPHALOPATHY GRADE III
ANEMIA OF CHRONIC DISEASE
TYPE II DIABETES MELLITUS WITH DIABETIC RETINOPATHY CHRONIC NON HEALING ULCER OVER RIGHT LEG
CKD ON MHD
Case History and Clinical Findings
C/O PAIN ABDOMEN
H/O UPPER LIMB AND LOWER LIMB EDEMA NO H/O FEVER H/O OF VOMITINGS WITH 3 EPISODES OF FOOD AS CONTENT H/O DECREASED URINE OUTUT
H/O OF ULCER OVER RIGHT LOWER LEG SINCE 5 MONTHS HEALING H/O CONSUMPTION ONCE IN 2 DAYS PASSING FLATUS AND STOOLS PAST HISTORY:
K/C/O HTN 2 YEAR AND ON MEDICATION TAB TELMA 40 MG PO/OD K/C/O DM SINCE 10 YRS
N/K/C/O SEIURES ,CAD,CVA,TB ,THYROID DISORDERS, ASTHMA
PERSONAL HISTORY APPETITE NORMAL
SLEEP ADEQUATE
BOWEL MOVEMENTS REGULAR DECREASED URINE OUTPUT ADDICTIONS :NO
FAMILY HISTORY NOT SIGNIFICANT
GENERAL EXAMINATION
PT IS CONCIOUS COHERENT AND COOPERATIVE
NO PALLOR ICTERUS CYANOSIS CLUBBINGLYMPHADENOPATHY PEDAL EDEMA - PRESENT
VITALS:
TEMPERATURE AFEBRILE BP 110/70 MM HG
PR 108 BPM
RR 20 CPM SPO2 99 AT RA
SYSTEMIC EXAMINATION RS :DYSPNEIC, BAE + NVBS
PA - SOFT,NON TENDER,NO ORGANOMEGALY CVS - S1S2 HEARD,
CNS -NFND
DAILYSIS SESSION:
12/12//24
04/12/24
16/12/24
21/12/24
24/12/24
27/12/24
Investigation
CBP HB 9.5
TC 8900
N 72
L 24
E 00
M 04
B 00
PLT 96000
SMEAR NORMOCYTIC NORMOCHROMIC ANEMIA WITH THROMBOCYTOPENIA
LIVER FUNCTION TEST (LFT) 10-11-2024 02:49:PMTotal Bilurubin 1.12mg/dlDirect Bilurubin 0.21 mg/dlSGOT(AST) 22 IU/LSGPT(ALT) 23IU/LALKALINE PHOSPHATASE 1112 IU/LTOTAL PROTEINS 4 gm/dlALBUMIN 1.19 gm/dlA/G RATIO 0.42
LIVER FUNCTION TEST (LFT) 25-12-2024 02:49:PMTotal Bilurubin 1.10mg/dlDirect Bilurubin 0.20 mg/dlSGOT(AST) 26 IU/LSGPT(ALT) 19IU/LALKALINE PHOSPHATASE 893 IU/LTOTAL PROTEINS 4 gm/dlALBUMIN 1 gm/dlA/G RATIO 0.33
Anti HCV Antibodies - RAPID M Non ReactiveHBsAg-RAPID Negative
RFT 10-12-2024 UREA 69 mg/dlCREATININE 5.5 mg/dlURIC ACID 5.1 mmol/LCALCIUM 9.8
mg/dlPHOSPHOROUS 3.3 mg/dlSODIUM 138 mmol/LPOTASSIUM 3.1 mmol/L.CHLORIDE 104
mmol/L
RFT 11-12-2024 UREA 79 mg/dlCREATININE 69 mg/dlURIC ACID 5.2 mmol/LCALCIUM
8.6mg/dlPHOSPHOROUS 3.7 mg/dlSODIUM 138 1131mmol/LPOTASSIUM 3.4 mmol/L.CHLORIDE
106mmol/L
RFT 22-12-2024 UREA 69 102/dlCREATININE 6.8mg/dlURIC ACID 5..5 mmol/LCALCIUM 8.4
mg/dlPHOSPHOROUS 4.2 mg/dlSODIUM 138 mmol/LPOTASSIUM 4.2 mmol/L.CHLORIDE 106
mmol/L
RFT 25-12-2024 UREA 108mg/dlCREATININE 5.9 mg/dlURIC ACID 6 mmol/LCALCIUM 9
mg/dlPHOSPHOROUS 4.3 mg/dlSODIUM 135 mmol/LPOTASSIUM 4.1 mmol/L.CHLORIDE 103
mmol/L
RFT 26-12-2024 UREA 177mg/dlCREATININE 6mg/dlURIC ACID 6.1 mmol/LCALCIUM 8
mg/dlPHOSPHOROUS 4.3 mg/dlSODIUM 136 mmol/LPOTASSIUM 3.8 mmol/L.CHLORIDE 101
mmol/L
RFT 27-12-2024 UREA 72 mg/dlCREATININE 4.1 mg/dlURIC ACID 3.9 mmol/LCALCIUM
7.9mg/dlPHOSPHOROUS 2.91 mg/dlSODIUM 137 mmol/LPOTASSIUM 4.7 mmol/L.CHLORIDE
101mmol/L
RFT 28-12-2024 UREA 78 mg/dlCREATININE 4.4 mg/dlURIC ACID 4.2 mmol/LCALCIUM 7.8
mg/dlPHOSPHOROUS 3.29 mg/dlSODIUM 136 mmol/LPOTASSIUM 2.9 mmol/L.CHLORIDE 104
mmol/L
ABG 28/12/24
PH 7.37 7.35-7.45PCO2 27.7 mmHg 35-45 mmHgPO2 90.8 mmHg 85-95 mmHgHCO3 15.6
mmol/LSt.HCO3 17.4 mmol/LBEB -8.5 mmol/LBEecf -8.6 mmol/LTCO2 34.4 VOLO2 Sat 96.8 %O2 Count 8.2 vol %
ABG 30/12/24
PH 7.31 7.35-7.45PCO2 29.9 mmHg 35-45 mmHgPO2 72.3 mmHg 85-95 mmHgHCO3 14.8
mmol/LSt.HCO3 16.2 mmol/LBEB -10.0 mmol/LBEecf -10.1 mmol/LTCO2 32.9 VOLO2 Sat 91.8 %O2 Count 7.9 vol %
APTT 58 SEC
PT 30 SEC
INR 2.22 SECBLOOD GROUPING AND RH TYPE- B P RANDOM SUGAR RANDOM - 86MG/DL
SERUM IRON -57.2 UG/DL USG DONE ON 10/12/24:
IMPRESSION ; GROSS ASCITES B/L PLEURAL EFFUSION R>L B/L GRADE II RPD CHANGES
2D ECHO
-NO RWMA. PARADOXICAL IVS
-TRIVIAL TR ; NO PAH (RVSP-36MMHG)
-NO MR/AR ; NO AS/MS
-SCLEROTIC AV ; MV-AML
-EF>55% GOOD LV SYSTOLIC FUNCTION
-GRADE I DIASTOLIC DYSFUNCTION
-IVC SIZE (0.2IMS) COLLAPSING
-MINIMAL PE AND PLEURAL EFFUSION
Treatment Given(Enter only Generic Name)
FLUID RESTRICTION <1.5 L /DAY SALT RESTRICTION <2 G/DAY
INJ NORAD 2 AMP IN 46 ML NS@ 2.5 ML/HR
INJ MEROPENAM 500 MG IV/BD INJ ZOFER 4 MG I/BD
INJ TRANEXA 500 MG IV/BD
INJ VITAMIN K 10 MG IN 40 ML NS IV/OD INJ OCTREOTIDE 100 UG SC/TID
TAB NODOSIS 500 MG PO/OD TAB SHELCAL CT PO/OD CAP BIO D3 60000 IUPO/OD
T BACT OINTMENT FOR LA NEOSPORIN POWDER FOR LA NEPHROSAVE PROTEIN POWDER SYP LACTULOSE 30 ML PO/TID INJ LASIX 20 MG IV/OD
INJ HYDROCORTISONE 100 MG IV/BD PROCTOLYTIC ENEMA
AIR BED
FREQUENT POSITION CHANGE
Follow Up
A 44 YEAR OLD MALE, FARMER BY OCCUPATION, RESIDENT OF NALGONDA, IS A KNOWN CASE DECOMPENSATED CHRONIC LIVER DISEASE WITH CHRONIC KIDNEY DISEASE (STAGE V ) WITH TYPE II DIABETES AND MELLITUS ,HTN WAS RE-ADMITTED FOR Maintenance HEMODIALYSIS AT THE TIME OF ADMISSION, PATIENT HAD COMPLAINTS OF ABDOMINAL DISTENTION AND DIFFUSE PAIN ABDOMEN, B/L PEDAL OEDEMA UPTO KNEES, SHORTNESS OF BREATH ON ORDINARY ACTIVITY AND DECREASED URINE OUTPUT. AT THE TIME OF ADMISSION, PATIENT VITALS WERE BP 110/70 mmHG, PR- 108BPM, RR-20cpm, Temp-98F GRBS-120mg/dl, SPO2, -99% on RA. CVS-S1S2 HEARD NO MURMURS ,R/S-NVBS HEARD; NO MURMURS PRESENT. P/A DISTENDED, FLUID THRILL PRESENT, BOWEL SOUNDS HEARD, NO ORGANEMELLALY PRESENT. CNS-HMF INTACT, NO FND. AT THE TIME OF ADMISSION, SERUM CREATININE -6.5, BLOOD UREA-55MG/DL NA+ - 138, K+-3.1. LFT :- TB- 1.12 MG\DL, DB-0.21MG\DL, SGOT-22 IU/L SGPT-23 IU/L ,ALP-1,112 IU/L, TP - 4.0, ALBUMIN-1.19 GM/DL HB-9.5 GM/DL, TLC-8,900 CELLS/CUMM, PLT- 96,000/CUMM
USG ABD- GROSS ASCITIS, WITH PLEURAL EFFUSION (R>L),B/L GRADE II RPD CHANGES. ASCITIC TAP WAS DONE, 400CELLS WITH 80% NEUTROPHILLS WERE PRESENT, SUGGESTIVE OF SPONTANEOUS BACTERIAL PERITONITIS,IV ANTIBIOTICS WERE STARTED.ON 24th DEC, PATIENT DEVELOPED HYPOTENSION DURING HEMODIALYSIS. INOTROPIC SUPPORT WAS STARTED LATER PATIENT BECAME DROWSY AND HIS SENSORIUM DETERIORATED OVER NEXT TWO DAYS PATIENT WAS IN HEPATIC ENCEPHALOPATHY.ASCITIC TAP WAS DONE ON 27th DEC, 200 CELLS WITH 100% LYMPHOCYTES WERE PRESENT. IV ANTIBIOTICS WERE CONTINUED I/V/O REFRACTORY HYPOTENSION 2° TO SEPSIS 2° TO SBP, INOTROPIC SUPPORT WAS CONTINUED. PATIENT SENSORIUM DETORIATED AND WAS IN GRADE III HEPATIC ENCEPHALOPATHY.THERAPEUTIC ASCITIC TAP WAS DONE. PROCTOLYTIC AMD LACTULOSE ENEMA WAS GIVEN 8th HOURLY AND CONSERVATIVE MANAGEMENT WAS CONTINUED.
OM 30TH DEC, AT 7:00PM, PATIENT DEVELOPED SUDDEN BRADYCARDIA AND FALL IN SATURATIONS CPR WAS STARTED ACCORDING TO LATEST ACLS GUIDELINES AND CRASH INTUBATION WAS DONE INSPITE OF THE ABOVE RESUSCITATIVE EFFORTS,PATIENT COULD NOT BE REVIVED AND DEATH WAS DECLARED AT 7:50PM 30/12/24.IMMEDIATE CAUSE OF DEATH:-1.SEPTIC SHOCK 2* TO SPONTANEOUS BACTERIAL PERITONITIS
2.HEPATIC ENCEPHALOPATHY (GRADE III)3. CHRONIC DECOMPENSATED LIVER DISEASE WITH ? OESOPHAGEAL VARICEAL BLEED .ANTECEDENT CAUSE OF DEATH:-1. ANEMIA OF CHRONIC DISEASE.2. TYPE II DM WITH DIABETIC RETINOPATHY.3. HYPERTENSION.4.
CHRONIC KIDNEY DISEASE ON MAINTAINENCE HEMODIALYSIS5. CHRONIC NON HEALING ULCER OVER RIGHT LEG
Death Date Date:30/12/24 Ward: ICU
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