THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASD INPUTS.
[21-06-2025 16:48] PPM 1: 55F developed fever a week ago followed by shortness of breath and then investigations in local hospital revealed mild varices followed by mild jaundice. History of toddy consumption not well quantified.
Was transferred here with shortness of breath.
[21-06-2025 16:49] PPM 1: On examination:
Metabolic syn phenotype
Tachypnoea
55F developed fever a week ago followed by shortness of breath and then investigations in local hospital revealed mild varices followed by mild jaundice. History of toddy consumption not well quantified.
Was transferred here with shortness of breath.
Pre intubation(17/6)
Post intubation(17/6)
18/6
20/6
Fever post hospitalization
Course of ventilation
[21-06-2025 17:08] PPM 1: Agitated saline test done by @PPM 3: https://youtube.com/shorts/JA7vqudtoDY?feature=shared
[21-06-2025 17:09] PPM 1: Left heart bubbles showing at the 6th cycle after injection of agitated saline 👇
[21-06-2025 17:10] PPM 1: Previous reading before procedure 👇
[21-06-2025 17:50] PPM 5: The CXR suggests infective etiology. We shouldn't diagnose HPS in presence of pneumonia.
[21-06-2025 17:50] PPM 5: The contrast echo needs to be repeated once pneumonia settles
[21-06-2025 17:51] PPM 5: Also the paO2 and A-aDO2 will be altered now due to the pneumonia itself
[21-06-2025 18:16] PPM 1: Thanks!
We were wondering what could be the other causes for a delayed right to left shunt demonstrable on agitated saline and possible false positives. @PPM4@Meta AI
[21-06-2025 18:16] Meta AI: Delayed right to left shunt on agitated saline study can be caused by several factors other than patent foramen ovale (PFO). Some possible causes include:
1. Intrapulmonary shunts: These can occur due to conditions like hepatopulmonary syndrome or hereditary hemorrhagic telangiectasia.
2. Cardiac shunts: Atrial septal defects (ASD) or ventricular septal defects (VSD) with Eisenmenger's syndrome can cause delayed shunting.
3. Pulmonary arteriovenous malformations (PAVMs): These abnormal connections between pulmonary arteries and veins can allow bubbles to bypass the capillary bed.
4. Technical factors: Over-agitation of saline, improper timing of injection, or equipment issues might lead to false positives.
False positives can also arise from:
1. Late bubbles: Appearance of bubbles after 3-5 cardiac cycles may indicate an intrapulmonary shunt rather than a cardiac shunt.
2. Poor image quality: Suboptimal echocardiogram images might lead to misinterpretation.
Would you like more details on any of these points or further clarification?
[21-06-2025 18:35] PPM 4: Delayed right-to-left shunting on agitated saline study (bubble echo) is typically associated with *intrapulmonary shunts* rather than immediate shunting seen with intracardiac shunts (e.g., PFO/ASD). However, several other causes and false positives can occur:
### I. Other Pathologic Causes of Delayed Shunting:
1. *Pulmonary Arteriovenous Malformations (PAVMs)*
- Most common cause of true delayed shunting (3-6 cardiac cycles post-opacification of RA).
- Associated with HHT (Hereditary Hemorrhagic Telangiectasia).
- Shunting occurs at capillary-alveolar level.
2. *Hepatopulmonary Syndrome (HPS)*
- Intrapulmonary vasodilation in chronic liver disease.
- Shunting worsens in upright position (orthodeoxia).
3. *Advanced Pulmonary Hypertension*
- Right heart pressure overload may reopen fetal shunts or cause functional shunting via dilated pulmonary vessels.
4. *Pulmonary Fistulas* (e.g., post-traumatic, surgical, or TB sequelae).
5. *Large Intrapulmonary Shunts* in congenital heart disease (e.g., unrepaired TOF).
---
### II. False Positives & Technical Pitfalls:
1. *Inadequate Agitation*
- Microbubbles too large → dissolve slowly, mimicking delayed appearance in LA.
- Fix: Use proper 9:1 saline-blood ratio, vigorous agitation.
2. *Contamination During Injection*
- Air introduced during injection → immediate bubbles in LA (can mimic PFO if timing is off).
- Fix: Flush tubing, avoid air in syringe.
3. *Echocardiographic Artifacts*
- "Swirling" in LA from poor acoustic windows misidentified as bubbles.
- Fix: Optimize imaging planes.
4. *Physiologic "Shunting" Without Pathology*
- Minimal delayed bubbles (≤3) can occur in healthy lungs due to incomplete filtration.
- Clinical cutoff: >3 bubbles in LA after 3 cycles is pathologic.
5. *Delayed Appearance Due to Slow Flow*
- Severe RV dysfunction → prolonged transit time.
- Mistaken for intrapulmonary shunt.
6. *Left Heart Catheterization Artifact*
- Agitated saline injected into pulmonary artery (e.g., during cath) may reflux into LA via pulmonary veins if LVEDP is high.
---
### III. Key Differentiation:
- *Immediate Shunting (≤3 cycles)*: Suggests intracardiac shunt (PFO/ASD).
- *Delayed Shunting (>3 cycles)*: Suggests intrapulmonary pathology (PAVM, HPS).
- *Persistent Bubbles in RA*: May indicate tricuspid regurgitation (not a shunt).
---
### IV. Workup for Confirmation:
1. *Repeat Echo with Provocation* (Valsalva/cough) to unmask PFO.
2. *Transesophageal Echo (TEE)*: Gold standard for PFO/ASD.
3. *CT Angiography*: Detects PAVMs.
4. *Contrast Transcranial Doppler*: Quantifies shunt severity.
5. *Liver function tests + SaO₂ in upright position*: For HPS.
Always correlate with clinical context (e.g., hypoxia, HHT features, liver disease). If uncertain, consult a cardiologist or pulmonologist for advanced testing.
[23-06-2025 15.52] PPM 1: Her initial history attached below.
Update
[24-06-2025 16:50] Rakesh Biswas Sir: @CR final EMR summary
Age/Gender: 55 Years/Female
Address:
Discharge Type: Expired
Admission Date: 17/06/2025 02:57 PM
Death Date:
Name of Treating Faculty
(AP)
Diagnosis
ALTERED SENSORIUM SECONDARY TO METABOLIC ENCEPHALOPATHY
[ HEPATIC &SEPTIC ENCEPHALOPATHY , OBESITY HYPOVENTILATION SYNDROME ]
SEPTIC SHOCK SECONDARY TO ? VENTILATOR ACQUIRED PNEUMONIA
DECOMPENSATED CHRONIC LIVER DISEASE WITH
ESOPHAGEAL VARICES , ? HEPATO PULMONARY SYNDROME
CARDIOGENIC SHOCK WITH ACUTE PULMONARY EDEMA [ RESOLVED ]
SECONDARY TO CAD
IRON DEFICIENCY ANEMIA SECONDARY TO GI LOSS
GRADE II BED SORE OVER RIGHT GLUTEAL REGION
K/C/O HYPERTENSION
ON MECHANICAL VENTILATION DAY 7
Case History and Clinical Findings
C/O BREATHLESSNESS SINCE TODAY MORNING
HOPI:
PT WAS APPARENTLY ASYMPTOMATIC 10 DAYS AGO. THEN DEVELOPED FEVER, LOW
GRADE, A/W PEDAL EDEMA, SINCE THEN, PT WAS TAKEN TO OUTSIDE HOSPITAL.
EVALUATION WAS DONE , DIAGNOSED AS ALCOHOLIC LIVER DISEASE WITH ESOPHAGEAL
VARICES, LATER DISCHARGED.
SINCE THEN C/O GENERALISED WEAKNESS, PROGRESSION OF PEDAL EDEMA, FACIAL
PUFFINESS.
** Tentative Date Page-2
KIMS HOSPITALS
C/O BREATHLESSNESS SINCE TODAY MORNING PROGRESSED FROM GRADE II - IV BY
EVENING , A/W ORTHOPNEA
H/O YELLOWISH DISCOLOARTION OF EYES PRESENT
H/O FEVER ONLY FOR 1 DAY, 1 WEEK AGO
H/O LOSS OF APETITE,
NO H/O DECREASED URINE OUTPUT
NO H/O NAUSEA, VOMITING, CHEST PAIN, ABDOMINAL DISTENTION
NO H/O CONSTIPATION, COUGH, COLD, PAIN ABDOMEN
NO H/O BURNING MICTURITION, PALPITATIONS
H/O PAST ILLNESS:
NO H/O SIMILAR COMPLAINTS IN THE PAST
K/C/O HYPERTENSION SINCE 20 YEARS
NOT A K/C/O TYPE 2 DM, CVA, CAD, ASTHMA,THYROID DISORDERS
TREATMENT HISTORY: NO SIGNIFICANT TREATMENT HISTORY
PERSONAL HISTORY: MARRIED, LOST APPETITE, NON VEG, REGULAR BOWELS, NO
ALLERGIES,
ALCOHOLIC SINCE 20 YRS . LAST BINGE 7 DAYS BACK FOR 20 DAYS. CONSUMES WHISKY
AND TODDY
NO SIGNIFICANT FAMILY HISTORY
GENERAL EXAMINATION:
PEDAL EDEMA - PITTING TYPE , EXTENDING UPTO BELOW KNEE
NO PALLOR, ICTERUS,CYANOSIS, CLUBBING,LYMPHADENOPATHY,MALNUTRITION.
VITALS:
TEMP: 98.7 F, PR: 156, RR:38,BP: 160/110 MMHG SPO2:86% ON ROOM AIR , GRBS: 167MG /DL
SYSTEMIC EXAMINATION:
CVS :S1 S2 + , RS: B/L DIFFUSE COARSE CREPITATIONS PRESENT
ABDOMEN: SOFT, BOWEL SOUNDS PRESENT
CNS: CONSCIOUS,NORMAL SPEECH,NO MENINGEAL SIGNS,GCS E4V5M6.
Investigation
17/06/25
Anti HCV Antibodies- RAPID Non Reactive
COMPLETE URINE EXAMINATION (CUE)
** Tentative Date Page-3
KIMS HOSPITALS
COLOUR Pale yellow Pale Yellow Physical Examination APPEARANCE Clear
Physical Examination REACTION Acidic 5.0-9.0 SP.GRAVITY ALBUMIN Nil Negative SUGAR ++
BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-3 0-5/HPF EPITHELIALCELLS 2-3 0-5/HPF
LRED BLOOD CELLS Nil 0-2/HPF CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent
OTHERS Nil, HBsAg-RAPID Negative
HAEMOGLOBIN 12.1 gm/dl TOTAL COUNT 17,600 cells/cumm NEUTROPHILS 80 %
LYMPHOCYTES 10 % EOSINOPHILS 00 % MONOCYTES 10 % BASOPHILS 00 % PCV 33.1 vol % M C V 97.4 fl M C H 35.6 pg M C H C 36.6 % RDW-CV 15.8 % RDW-SD 54.1 fl RBC COUNT 3.40 millions/cumm PLATELET COUNT 3.32 lakhs/cu.mm RBC Normocytic normochromic WBC Increased
in count PLATELETS Adeqaute HEMOPARASITES No hemoparasites seen Light Microscopy
HIV 1/2 Rapid Test Non Reactive
Total Bilurubin 4.61 mg/dl Direct Bilurubin 2.61 mg/dl SGOT(AST) 110 IU/L 0SGPT(ALT) 70 IU/L
ALKALINEPHOSPHATASE475 IU/L TOTAL PROTEINS 5.5 gm/dl ALBUMIN 3.05 gm/dl A/G RATIO 1.24
Serum Creatinine 0.4 mg/dl
Blood Urea 18 mg/dl
SODIUM 139 mmol/L POTASSIUM 3.7 mmol/L CHLORIDE 104 mmol/L CALCIUM IONIZED 1.15
mmol/L
.STOOL FOR OCCULT BLOOD Positive (+ve)
APTT TEST 32 Sec
Prothrombin Time 16 Sec
INR 1.11
TROPONIN-I 580.3
PH 7.357 PCO2 36.7 mmHGPO2 122 mmHg HCO3 20.1 mmol/LSt.HCO3 20.8 mmol/L
HAEMOGLOBIN 11.0 gm/dl 12.0 - 15.0 TOTAL COUNT 22,900 cells/cumm NEUTROPHILS 85 %
EOSINOPHILS 01 % BASOPHILS 00 % PCV 31.9 vol %M C V 103.4 flM C H 35.7 M C H C 34.6 %
RDW-CV 16.4 % RDW-SD 61.9 fl RBC COUNT 3.08 millions/cumm PLATELET COUNT 3.66
lakhs/cu.mm 1SMEARWBC increased counts on smear with neutrophilia PLATELETS Adeqaute
HEMOPARASITES No hemoparasites seen Light
PH 7.359 7.35-7.45PCO2 34.0 mmHg 35-45 mmHgPO2 99.6 mmHg 85-95 mmHgHCO3 18.7
mmol/LSt.HCO3 19.8 mmol/LBEB -5.6 mmol/LB Eecf -5.8 mmol/LTCO2 39.3 VOLO2 Sat 99.6 %O2
Count 13.4 vol %
Blood Lactate 16.2 mg/dl
18/6/25
** Tentative Date Page-4
KIMS HOSPITALS
PH 7.20 7.35-7.45PCO2 48.2 mmHg PO2 68.5 mmHg HCO3 18.4 mmol/LSt.HCO3 17.2 mmol/LBEB
18.4 mmol/LB Eecf -6.0 mmol/LTCO2 -8.1 VOLO2 Sat 92.3 %O2 Count 15.1 vol %
PH 7.13 7.35-7.45 PCO2 67.2 mmHg PO2 122 mmHg HCO3 21.7 mmol/LSt.HCO3 17.9 mmol/LBEB -8.2 mmol/LB Eecf -6.2 mmol/LTCO2 46.8 VOLO2 Sat 97.7 %O2 Count 17.0 vol %
PH 7.35 7.35-7.45 PCO2 39.3 mmHg PO2 54.7 mmHg HCO3 21.5 mmol/LSt.HCO3 21.7 mmol/LBEB
-3.1 mmol/LB Eecf -3.1 mmol/LTCO2 45.5 VOLO2 Sat 90.0 %O2 Count 11.9 vol %
PH 7.34 7.35-7.45PCO2 44.7 mmHg PO2 74.3 mmHg HCO3 23.8 mmol/LSt.HCO3 23.3 mmol/LBEB
-1.3 mmol/LB Eecf -1.0 mmol/LTCO2 49.6 VOLO2 Sat 96.0 %O2 Count 14.6 vol %
STOOL FOR OCCULT BLOOD Negative (-ve)
19/6/25
PH 7.38 7.35-7.45PCO2 39.9 mmHg PO2 72.1 mmHg HCO3 23.3 mmol/LSt.HCO3 23.5 mmol/LBEB
-1.1 mmol/LB Eecf -1.1 mmol/L TCO2 48.8 VOLO2 Sat 95.9 %O2 Count 13.0 vol %
PH 7.37 7.35-7.45PCO2 40.0 mmHg PO2 70.4 mmHg HCO3 22.8 mmol/LSt.HCO3 23.0 mmol/LBEB
-1.7 mmol/LBEecf -1.6 mmol/LTCO2 48.2 VOLO2 Sat 95.3 %O2 Count 12.1 vol %
COLOUR Pale yellow Pale Yellow Physical Examination APPEARANCE Clear
Physical Examination REACTION Acidic 5.0-9.0 SP. GRAVITY 1.010 ALBUMIN + Negative SUGAR ++ Negative BILE SALTS Nil Negative BILE PIGMENTS Nil Negative PUS CELLS 4-5 0-5/HPF
EPITHELIAL CELLS 1-2 0-5/HPF RED BLOODCELLS5-6 0-2/HPF CRYSTALS Nil CASTS Nil
AMORPHOUS DEPOSITS Absent Nil OTHERS Nil
HAEMOGLOBIN 10.5 gm/dl TOTAL COUNT 15,800 cells/cumm NEUTROPHILS 80 %
LYMPHOCYTES 12 % EOSINOPHILS 01 % MONOCYTES 07 % BASOPHILS 00 % PCV 31.3 vol
%M C V 105.2 fl M C H 35.4 pg M C H C 33.6 % RDW-CV 16.5 % RDW-SD 62.0 fl RBC COUNT 2.9 millions/cumm PLATELET COUNT 3.4 lakhs/cu.mm SMEAR RBC Normocytic normochromic WBC
increased on smear PLATELETS Adeqaute HEMOPARASITES No hemoparasites seen
Blood Urea 15 mg/dl
Total Bilurubin 4.81 mg/dl Direct Bilurubin 2.62 mg/dl SGOT(AST) 114 IU/L SGPT(ALT) 55 IU/L
ALKALINEPHOSPHATASE420 IU/L TOTAL PROTEINS 5.3 gm/dl ALBUMIN 2.84 gm/dl A/G RATIO1.15, Serum Creatinine 0.5 mg/dl
PH 7.35 7.35-7.45PCO2 46.2 mmHgPO2 28.6 mmHg HCO3 25.0 mmol/LSt.HCO3 23.6 mmol/LBEB -
0.2 mmol/LBEecf 0.1 mmol/LTCO2 53.3 VOLO2 Sat 53.7 %O2 Count 7.2 vol %SODIUM 143 mmol/L POTASSIUM 2.8 mmol/L CHLORIDE 101 mmol/L 98 - 107 CALCIUM IONIZED 1.06 mmol/LPH 7.167 7.35-7.45PCO2 76.7 mmHg 35-45 mmHgPO2 76.7 mmHg 85-95 mmHgHCO3 26.7
mmol/LSt.HCO3 22.0 mmol/LBEB -2.7 mmol/L BEecf -1.0 mmol/LTCO2 58.5 VOLO2 Sat 92.0 %O2
Count 13.2 vol %
** Tentative Date Page-5
KIMS HOSPITALS
HAEMOGLOBIN 10.4 gm/dl TOTAL COUNT 14,000 cells/cumm NEUTROPHILS 83 %
LYMPHOCYTES 10 % EOSINOPHILS 01 % MONOCYTES 06 % BASOPHILS 00 % PCV 30.3 vol % M C V 104.5 flM C H 35.9 pg M C H C 34.3 % RDW-CV 17.7 % RDW-SD 64.2 fl RBC COUNT 2.9 millions/cumm PLATELET COUNT 3.2 lakhs/cu.mm SMEAR RBC Normocytic normochromic WBC increased counts on smear with neutrophilia Light Microscopy PLATELETS Adequate in number and distribution HEMOPARASITES No hemoparasites seen IMPRESSION Neutrophilic leucocytosis.
STOOL FOR OCCULT BLOOD positive (+ve)
PH 7.31 7.35-7.45PCO2 34.8 mmHg 35-45 mmHg PO2 119 mmHg 85-95 mmHgHCO3 17.2
mmol/LSt.HCO3 18.2 mmol/LBEB -7.7 mmol/LB Eecf -7.8 mmol/LTCO2 36.9 VOLO2 Sat 98.3 %O2
Count 12.7 vol %
UREA 19 mg/dl CREATININE 0.5 mg/dl URIC ACID 2.7 mmol/L CALCIUM 9.6 mg/dl
PHOSPHOROUS 2.4 mg/dL SODIUM 144 mmol/L POTASSIUM 3.2 mmol/L. CHLORIDE 104 mmol/L
20/6/25
PH 7.32 7.35-7.45PCO2 49.1 mmHg 35-45 mmHgPO2 85.9 mmHg 85-95 mmHgHCO3 24.6
mmol/LSt.HCO3 23.5 mmol/LBEB -1.1 mmol/LB Eecf -0.7 mmol/LTCO2 52.9 VOLO2 Sat 96.9 %O2
Count 11.7 vol %
PH 7.28 7.35-7.45PCO2 55.2 mmHg 35-45 mmHgPO2 88.0 mmHg 85-95 mmHgHCO3 25.5
mmol/LSt.HCO3 23.5 mmol/LBEB -1.0 mmol/LB Eecf -0.3 mmol/LTCO2 54.5 VOLO2 Sat 96.5 %O2
Count 13.1 vol %
UREA 19 mg/dl CREATININE 0.8 mg/dl URIC ACID 2.8 mmol/L CALCIUM 8.9 mg/dl
PHOSPHOROUS 2.5 mg/dl SODIUM 148 mmol/L POTASSIUM 2.8 mmol/L. CHLORIDE 104 mmol/L
PH 7.30 PCO2 53.1 mmHg PO2 48.4 mmHg HCO3 25.4 mmol/LSt.HCO3 23.5 mmol/LBEB -0.8
mmol/LBEecf -0.2 mmol/LTCO2 54.3 VOLO2 Sat 82.7 %O2 Count 11.2 vol %
PH 7.30 PCO2 45.1 mmHg PO2 136 mmHgHCO3 21.7 mmol/LSt.HCO3 21.1 mmol/LBEB -3.9
mmol/LBEecf -3.7 mmol/LTCO2 46.7 VOLO2 Sat 98.8 %O2 Count 12.3 vol %
HAEMOGLOBIN 9.2 gm/dl TOTAL COUNT 13,400 cells/cumm NEUTROPHILS 78 %
LYMPHOCYTES 14 % EOSINOPHILS 01 % MONOCYTES 07 % BASOPHILS 00 % PCV 27.9 vol % M C V 108.5 fl M C H 35.7 pg M C H C 32.9 % RDW-CV 18.2 %RDW-SD 70.4 fl RBC COUNT 2.57
millions/cumm PLATELET COUNT 2.51 lakhs/cu.mm SMEARRBC Normocytic normochromic WBC
increased counts on smear PLATELETS Adequate in number and distribution HEMOPARASITES No
hemoparasites
Total Bilurubin 3.91 mg/dL Direct Bilurubin 3.60 mg/dl SGOT(AST) 152 IU/L SGPT(ALT) 44 IU/L
ALKALINE PHOSPHATASE 363 IU/L TOTAL PROTEINS 4.8 gm/dl ALBUMIN 2.5 gm/dl A/G RATIO 1.09
UREA 24 mg/dl CREATININE 0.9 mg/dl URIC ACID 3.4 mmol/L CALCIUM 9.6 mg/dl 8.6 -
10.2PHOSPHOROUS 2.4 mg/dl SODIUM 145 mmol/L POTASSIUM 3.2 mmol/L. CHLORIDE 104
mmol/L
** Tentative Date Page-6
KIMS HOSPITALS
21/6/25
APTT TEST 33 Sec
Prothrombin Time 17 Sec 10-16secINR 1.25
COLOUR Reddish Pale Yellow Physical Examination APPEARANCE Clear
Physical Examination REACTION Acidic 5.0-9.0 SP. GRAVITY 1.010 ALBUMIN ++ SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-3 0-5/HPF EPITHELIAL CELLS 1-2 0-5/HPF RED BLOOD CELLS Nil 0-2/HPF CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent Nil
OTHERS Fungal hyphae present Nil Light Microscopy
CELL COUNT C S F COLOUR Colourless APPEARANCE Clear QUANTITY 1 Ml TOTAL COUNT 0 cells/cumm LYMPHOCYTES Nil %MONOCYTES Nil %RBC Nil HPF OTHERS Nil
SUGAR 64 mg/dl PROTEIN 56 mg/dl. CHLORIDE 124 mmol/L 116 - 127.CULTURE AND
SENSITIVITY - NO ACID FAST BACILLI SEEN
OCCASIONAL INFLAMMATORY CELLS , FEW GRAM POSITIVE COCCIN IN SINGLES , PAIRS
AND OCCASIONAL GRAM POSITIVE BACILLI SEEN ,NO GROWTH AFTER 48 HOURS OF
INCUBATION
PH 7.30 PCO2 41.8 mmHg PO2 93.5 mmHg HCO3 20.3 mmol/LSt.HCO3 20.2 mmol/LBEB -5.0
mmol/LBEecf -4.9 mmol/LTCO2 44.0 VOLO2 Sat 97.0 %O2 Count 11.4 vol %
SODIUM 148 mmol/L POTASSIUM 3.0 mmol/L CHLORIDE 107 mmol/L CALCIUM IONIZED 1.15
mmol/L .
PH 7.338 7.35-7.45PCO2 42.2 mmHg PO2 43.7 mmHg HCO3 22.0 mmol/LSt.HCO3 21.6
mmol/LBEB -3.0 mmol/LBEecf -2.9 mmol/LTCO2 47.5 VOLO2 Sat 74.4 %O2 Count 8.8 vol %
Blood Lactate 15.0 mg/dl
RFTUREA 25 mg/dl CREATININE 1.1 mg/dl URIC ACID 3.5 mmol/L CALCIUM 9.0 mg/dl
PHOSPHOROUS 2.8 mg/dl SODIUM 157 mmol/L POTASSIUM 2.8 mmol/L. CHLORIDE 106 mmol/L
22/6/25
ABG Test Result Units Normal Range PH 7.355 PCO2 39.8 mmHg PO2 80.3 mmHg HCO3 21.7
mmol/LSt.HCO3 21.9 mmol/LBEB -3.0 mmol/LBEecf -3.0 mmol/LTCO2 46.5 VOLO2 Sat 95.8 %O2
Count 11.2 vol %
APTT TEST 33 Sec
Prothrombin Time 16 Sec 10-16secINR 1.11
HAEMOGLOBIN 8.4 gm/dl TOTAL COUNT 12,400 cells/cumm NEUTROPHILS 84 %
LYMPHOCYTES 10 % EOSINOPHILS 01 % MONOCYTES 05 % BASOPHILS 00 % PLATELET
COUNT 1.74 lakhs/cu.mm SMEAR Normocytic normochromic anemiawith neutrophilic
leukocytosis Light Microscopy
BLEEDING TIME 2 Min 30 sec 2-7 Mins CLOTING TIME 5 Min 00 sec 1-9 Mins. BLOOD GROUP:
ARH TYPING: POSITIVE (+VE)
** Tentative Date Page-7
KIMS HOSPITALS,
PH 7.29 7.35-7.45PCO2 44.1 mmHg PO2 50.4 mmHg HCO3 20.9 mmol/LSt.HCO3 20.4 mmol/LBEB
-4.6 mmol/LBEecf -4.4 mmol/LTCO2 46.2 VOLO2 Sat 80.7 %O2 Count 8.0 vol %
RBS 87 mg/dl.
SODIUM 149 mmol/L POTASSIUM 2.9 mmol/LCHLORIDE 106 mmol/L CALCIUM IONIZED 1.10
mmol/L
.PH 7.31 7.35-7.45PCO2 33.5 mmHg PO2 106 mmHg HCO3 16.5 mmol/LSt.HCO3 17.5 mmol/LBEB
-8.5 mmol/LBEecf -8.6 mmol/LTCO2 35.7 VOLO2 Sat 97.6 %O2 Count 10.9 vol %
HAEMOGLOBIN 8.8 gm/dl TOTAL COUNT 14,100 cells/ NEUTROPHILS 84 % LYMPHOCYTES 12 % EOSINOPHILS 01 % MONOCYTES 03 % BASOPHILS 00 % PCV 27.4 vol % M C V 111.6 fl M C H 36.0 pg M C H C 32.3 % RDW-CV 17.6 % RDW-SD 70.2 fl RBC COUNT 2.45 millions/cumm
PLATELET COUNT 1.61 lakhs/cu.mm SMEARRBC Normocytic normochromic Light Microscopy WBC increased counts on smear with neutrophiliaLight Microscopy PLATELETS Adequate in number and distribution Light Microscopy HEMOPARASITES No hemoparasites seen Light
Microscopy IMPRESSION Neutrophilic leucocytosis.
Total Bilurubin 5.20 mg/dl 0 - 1 Direct Bilurubin 3.45 mg/dl SGOT(AST) 267 IU/LSGPT(ALT) 66 IU/L ALKALINE PHOSPHATASE311 IU/L TOTAL PROTEINS 4.8 gm/dl ALBUMIN 2.39 gm/dl A/G RATIO 0.99
UREA 28 mg/dl CREATININE 0.9 mg/dl URIC ACID 3.5 mmol/L CALCIUM 9.0 mg/dl
PHOSPHOROUS 3.2 mg/dl SODIUM 148 mmol/L POTASSIUM # 2.6 mmol/LCHLORIDE 107 mmol/L
23/6/25
ABG
PH 7.26 7.35-7.45PCO2 45.1 mmHgPO2 42.7 mmHg HCO3 19.6 mmol/LSt.HCO3 18.6 mmol/LBEB -
6.6 mmol/LBEecf -6.3 mmol/LTCO2 42.9 VOLO2 Sat 67.3 %O2 Count 8.0 vol %
2D ECHO: DONE ON 18/6/25
TACHY CARDIA DURING STUDY
NO RWMA CONMCENTRIC LVH+
MILD AR+(AR PHT 727 M/SEC)
MILD TR+ WITH PAH :(eccentric JET TR+)
RVSP: 42105247 MM HG
TRIVIAL MR, NO PR
SCLEROTIC AV, NO AS/MS IAS INTACT
EF2 59% GOOD 2V SYSTOLIC FUNCTION
GRADE 1 DIASTOLIC DYSFUNCTION
IVC SIZE (1.0 CMS) COLLAPSING
** Tentative Date Page-8
KIMS HOSPITALS
NO PE: NO LV CLOT
IVS = (1.40 CMS
EDD= 5.3 CMS
ESD 3.7 CMS
DPW 1.4 CMS
MRI IMPRESSION DONE ON 21/6/25
MILD DIALTION OF PERI OPTIC CSF SPACES
PARTIALLY EMPTY SELLA
USG IMPRESSION DONE ON 18/6/25
MILD HEPATOMEGALY WITH GRADE 2 FATTY LIVER
BLOOD CULTURE AND SENSITIVITY DONE ON 19/6/25
NO GROWTH AFTER 48 HOURS OF AEROBIC INCUBATION
CSF CULTURE AND SENSITIVITY DONE ON 23/6/25
NO GROWTH AFTER 48 HRS OF AEROBIC INCUBATION
URINE CULTURE AND SENSITIVITY DONE ON 19/6/25
NO BACTERIAL GROWTH
Treatment Given (Enter only Generic Name)
RT FEEDS WATER 100ML 2ND HOURLY
MILK 100ML 4RTH HOURLY
IVF NS @ 75ML ML/H
INJ. NORAD 8MG IN 46 ML NS @ 10/HR 10.16MG/ML TAPERED ACCORDINGLY
INJ DOBUTAMINE 1 AMP [250MG] IN 45ML NS @ 4.5 ML/HR TAPERED ACCORDINGLY
INJ. MIDAZ 30ML [30MG] @ 4ML/HR WEANED ACCORDINGLY
INJ VASOPRESSIN 2ML [400] IN 38 ML NS @ 2.4 ML/HR STARTED ON DAY 2 INCREASED OR
DECREASED TO MAINTAIN MAP 65MMHG
INJ PIPTAZ 4.5 GM IV TID GIVEN 4 DAYS
INJ CLINDAMYCIN 600MG IV TID FOR 4 DAYS
** Tentative Date Page-9
KIMS HOSPITALS
INJ MEROPENEM 1GM IV TID STARTED ON DAY 5 GIVEN FOR 2 DAYS
INJ LINEZOLID 600 MG IV TID STARTED ON DAY 5 GIVEN FOR 2 DAYS
INJ PAN 40 MG IV OD
INJ LASIX 20 MG IV BD IF SBP >110MMHG
INJ MANNITOL 20 GM (100) MG IV TID
INJ THIAMINE 500 MG IV STAT
INJ THIAMINE 200MG IV BD
INJ NEOMOL 1 GM 50 ML IV QID
TAB. ECOSPRIN AV 75/20MG RT HS 0-0-1
TAB RIFAGUT 550 MG RT BD
TAB UDIUV 300 MG RT BD
TAB HEPAWIN FORTE RT BD
SYP POTCHLOR 15ML RT QID
SYP LACTULOSE 20 ML RT TID
INJ KCL 3 AMP+ MGSO41 AMP IN 0.45% NS IV OVER 6 HOURS
INJ VIT K 10MG IN 100ML NS IV OD 3 DOSES GIVEN
NEB WITH IPRAVENT AND BUDECORT 6 HOURLY
FREQUENT POSITION CHANGE
AIR BED, ET ORAL SUCTIONING 2ND HOURLY
TEPID SPONGING, ICE PACKS
CHEST PHYSIOTHERAPY
Follow Up
DEATH SUMMARY:
** Tentative Date Page-10
KIMS HOSPITALS
A 55 YR OLD FEMALE HYPERTENSIVE SINCE 20 YR WAS BROUGHT TO CASUALITY WITH
COMPLAINTS OF BREATHLESS SINCE MORNING, PEDAL EDEMA AND GENERALISED
WEAKNESS SINCE 3 DAYS. AT PRESENTATION. VITALS BP 160/90MM HG. PR 150BPM, TEMP 98, SPO2 86 ON RA WITH 91% ON FULL FLOW O2, GRBS 167.ABG: PH: 7.2 PCO2: 48.2, PO2:68.4 , SO2: 92, HCO3 :18.4. ON AUSCULTATION B/L DIFFUSE COARSE CREPITATIONS
PRESENT. IMMEDIATE MANAGEMENT WAS DONE WITH O2 SUPPLEMENTATION WITH INJ
LASIX 40MG IV STAT WAS GIVEN AND PATIENT WAS IMMEDIATELY SHIFTED TO ICU. PT
SENSORIUM WORSENED FROM THE MORNING AS TOLD BY PT ATTENDERS ON FURTHER
HISTORY IT WAS FOUND THAT PATIENT WAS DIAGNOSED WITH DECOMPENSATED
CHRONIC LIVER DISEASE SECONDARY TO ALCOHOL WITH ESOPHAGEAL VARICES 1 WEEK AGO ADMITTED AND TREATED FOR 3 DAYS. ALL NECESSARY INVESTIGATIONS WERE SENT INCLUDING BLOOD AND URINE CULTURES. CONNECTED TO CPAP VENTILATION AND REPEATED ABG AFTER 30MIN. PH: 7.2, PCO2: 65.3, PO2: 89.9, SO2: 99.7, HCO2 :26.2.
INTUBATION WAS DONE I/V/O CO2 RETENTION AND WORSENING SENSORIUM AND
CONNECTED TO MECHANICAL VENTILATOR. MODE ACMV-VC MODE, PEEP :5, VT :420 ML, FIO2 :100%, I:E 1:2, PR :14. POST INTUBATION I/V/O HYPOTENSION AND LV DYSFUNCTION (IN 2D ECHO SCREENING) STARTED ON IONOTROPE SUPPORT WITH INJ NORADRENALINE AND DOBUTAMINE SEDATION AND PARALYTICS WERE ALSO STARTED.
STARTED ON ANTIBIOTICS AND OTHER SUPPORTIVE TREATMENT AND MONITORED FREQUENTLY I/V/O
NO IMPROVEMENT WITH DUAL IONOTROPIC SUPPORT 3RD IONOTROPE INJ VASOPRESSIN WAS STARTED ON SAME DAY. LATER ON DAY 2 SEDATION AND PARALYTIC SUPPORT WERE STOPPED AND SENSORIUM IMPROVED GRADUALLY WITH GCS E4VTM6.
SPONTANEOUS BREATH TRIAL WAS DONE THERE WAS NO RESPIRATORY DISTRESS AND
VITALS WERE STABLE WITH DECREASING IONOTROPIC REQUIREMENT. WEANING OFF
FROM VENTILATOR WAS TRIED, BUT COULD NOT TOLERATE. T PIECE LEADING TO CO2
RETENTION SO SWITCHED TO CPAP MODE AND CONTINUED SAME TREATMEMENT. LATER ON DAY 3, CO2 RETENTION INSPITE ADEQUATE VENTILATORY SUPPORT CONTINUED. ON D
** Tentative Date Page-11
KIMS HOSPITALS
DAY 4 SENSORIUM WAS WORSENING [GCS -E3VTM6(OBEYS EYE COMMANDS ONLY). ON
DAY 4 NOTICED NO RESPIRATORY EFFORTS SO CONTINUED WITH ACMV VC MODE WITH
SEDATION AND PARALYTIC SUPPORT. FEVER SPIKES STARTED FROM DAY 3. CONTINOUS
HIGH GRADE FEVER SPIKES FROM DAY 4. ON DAY 5 MORNING STOPPED SEDATION AND
PARALYTIC SUPPORT AND SPONTANEOUS BREATH TRAIL DONE BUT THERE WAS NO
RESPIRATORY EFFORT WITH QUADRIPLEGIA, INTACT BRAIN STEM REFLEX. PUPILS MILD DILATED, SLUGGISH REACTION. PRESERVED EYE MOVEMENTS. I/V/O SUSPICION OF CEREBRAL EDEMA / PONTINE LESION, MRI BRAIN WAS DONE SHOWING RAISED ICT
FEATURES AND CONFIRMED WITH FUNDUS EXAMINATION. STARTED ON ANTIEDEMA
MEASURES. LUMBAR PUNCTURE WAS DONE I/V/O MENINGOENCEPHALITIS REVEALED NO CELLS, NO GROWTH, ANTIBIOTICS WAS ESCALATED I/V/O CONTINOUS HIGH GRADE
FEVER SPIKES. THERE WAS SERIAL DROP IN HEMOGLOBIN AND STOOL FOR OCCULT
BLOOD POSITIVE AND PLANNED FOR BLOOD TRANSFUSION ON DAY 7. . ON DAY 6 AND
DAY 7 TREATMENT WAS CONTINUED AND MONITORED BUT NO SIGNIFICANT
IMPROVEMENT IN PATIENT SENSORIUM AND CLINICAL CONDITION. ENT OPINION WAS
TAKEN IN VIEW OF TRACHEOSTOMY, PLANNED FOR IT ON DAY 8 BUT ON DAY 7 AT
AROUND 8:10 PM THERE WAS FALL IN SATURATION AND ABSENT CENTRAL AND
PERIPHERAL PULSATIONS, SO CPR WAS STARTED ROSA ACHIEVED AFTER 2 CYCLES.
LATER AROUND 10:40 PM CPR STARTED ACCORDING TO RECENT ACLS GUIDELINES.
DESPITE ABOVE RESUSCITATIVE EFORTS PATIENT COULDN'T BE REVIVED AND DECLARED DEATH AT AROUND 11:20 PM ON 23/6/2025
IMMEDIATE CAUSE OF DEATH
TYPE 1 RESPIRATORY FAILURE
CAD ACS NSTEMI
ALTERED SENSORIUM SECONDARY TO METABOLIC ENCEPHALOPATHY
(HYPOVENTILATION, HEPATIC ENCEPHALOPATHY)
MIXED CARDIOGENIC + SEPTIC SHOCK
ANTECEDENT CAUSE
DECOMPENSATED CHRONIC LIVER DISEASE WITH
ESOPHAGEAL VARICES? HEPATOPULMONARY SYNDROME
? VENTILATOR ACQUIRED PNEUMONIA
VENTILATOR ACQUIRED PNEUMONIA
IRON DEFICIENCY ANEMIA SECONDARY TO GI LOSS
GRADE II BED SORE
K/C/O HYPERTENSION
** Tentative Date Page-12
KIMS HOSPITALS
Death Date:23/6/2025
Ward: ICU
Unit: 1
Faculty Signature
SIGNATURE OF PATIENT /ATTENDER:
SIGNATURE OF PG/INTERNEE:
SIGNATURE OF ADMINISTRATOR:
SIGNATURE OF FACULTY:
[24-06-2025 16:53] PPM 1: Possibly died of nosocomial sepsis
Which nosocomial localisation?
The serial chest X-rays available till 20/6/25 is not highly suggestion of a ventilator association pneumonia?
@PPM3 let's gather the ET tube culture reports?
No urinary culture was sent after the development of the nosocomial fever?
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