23-09-2025
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 SERIESOF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[23-09-2025 16:31] PPM 1: 49F with Diabetes diagnosed during second childbirth 32 years ago
[23-09-2025 16:37] PPM 1: 49F with Diabetes diagnosed during second childbirth 32 years ago
Uneventful till 6 years back when she had a thorn prick in her right foot while walking outside her house and she developed a plantar abscess that had to be drained and debrided following which she suffered recurrence of the same few times since last six years. She developed swelling of both feet which progressed to whole body.
The left foot also started getting affected since a year before which she had a right femur fracture treated with internal fixation.
Since three days she has started developing shortness of breath.
Recent images of her diabetic foot
[23-09-2025 16.40] PPM 1: Image of her anasarca in upper limbs with peau de orange.
One report of serum albumin outside is 0.9
[24-09-2025 15.26] PPM 1: Update on investigations post admission yesterday:
As outside albumin was 0.9 here too it's just 1.0
Next step is to figure out the cause of her hypoalbuminemia which may have worsened over the last 2 months
[24-09-2025 15.29] PPM 1: @PPM3's history
We got 32 years of Diabetes first detected since her second childbirth.
We would be interested to know from her advocate as to how long she was on tablets for her diabetes and was insulin started only 6 years back from the first time she had the thorn prick Plantar abscess?
EMR summary:
Age/Gender: 49 Years/Female
Address:
Discharge Type: Expired
Admission Date: 23/09/2025 12:18 PM
Death Date: 25/09/2025 12:40 AM
Diagnosis
?PULMONARY THROMBOEMBOLISM
TYPE II RESPIRATORY FAILURE
DECOMPENSATED CHF WITH Ascites PRECOX WITH Pleural EFFUSION AND
PERICARDIAL EFFUSION
?COMMUNITY ACQUIRED PNEUMONIA
CELLULITIES OF B/L LOWER LIMBS? FILARIASIS
HYPOALBUMINEMIA,
HYPOKALEMIA SECONDARY TO? DRUG INDUCED
Case History and Clinical Findings
C/O SOB AND FEVER SINCE 4DAYS, INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE FROM GRADE III-IV AGGRAVITATED IN SUPINE POSITION ASS WITH COUGH WITH SCANTY SPUTUM SINCE 4DAYS NON BLOOD STAINED AND NON FOUL SMELLING AND FEVER HIGH GRADE A/W CHILLS+ H/O CHESTPAIN WHILE COUGHING PEDAL EDEMA (B/L PITTING TYPE) GRADE IV (ANASARCA-+)
H/O ABDOMINAL DISTENSION SINCE 1MONTH, GRADUALLY PROGRESSIVE AS WITH LOSS OF APPETITE
H/O SLIP AND FALL 1 YEAR BACK FOR WHICH SURGERY WAS DONE AND PT WALKED FOR 6-7 MONTHS LATER STOPPED WALKING SINCE 2 MONTHS UNABLE TO STAND UP
H/O ONE EPISODE OF VOMITING YESTERDAY FOOD AS CONTENT.H/O DECREASED URINE OUTPUT SINCE 2 MONTHS A/W BURNING MICTURITION AND RED COLOURED URINE O/E RED COLOURED LESION OVER INJECTION SITE
PAST HISTORY: K/C/O T2DM SINCE 32YRS ON INJ MIXTARD (7U-X-8U). K/C/O
HYPOTHYROIDISM SINCE ONE AND HALF YEAR ON TAB THYRONORM 125 MCG
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NO OTHER COMORBIDITIES.PERSONAL HISTORY: MARRIED, NORMAL APPETITE, MIXED
DIET, REGULAR BOWEL, DECREASED URINE OUTPUT.NO KNOWN ADDICTIONS AND
ALLERGIES
GENERAL EXAMINATION: NO PALLOR, NO ICTERUS, NO CYANOSIS, NO CLUBBING, NO
LYMPHADENOPATHY, NO PEDAL EDEMA.
VITALS: - TEMP: 102.3 F, BP: 120/60MMHG, RR: 30 CPM, PR: 103 BPM, SPO2: 94% AT
RA, GRBS:94 MG/DL
CVS-N, RS-BAE+, DIFFUSE B/L CREPITATIONS PRESENT, PER ABDOMEN -SOFT DISTENDED WITH PITTING EDEMA.
PULMONOLOGY REFERRAL WAS TAKEN AND ADVISE AS FOLLOWED
SURGERY REFERRAL WAS TAKEN I/V/O B/L LOWER LIMB CELLULITIS AND? DIABETIC FOOT ULCER AND ADVISE AS FOLLOWED
OPHTHAL REFERRAL WAS DONE FOR RETINOPATHY CHANGES -NORMAL FUNDUS
DEATH SUMMARY: 48/F KNOWN CASE OF DIABETIC AND HYPOTHYROIDISM WITH NO
ADDICTIONS CAME WITH C/O SOB AND FEVER ALONG WITH H/O PEDAL EDEMA
ABDOMINAL DISTENTION, BILATERAL DIABETIC FOOT ULCERT SINCE 4YEARS WHICH IS NON-HEALING FASCIOTOMY AND 2ND TOE AMPUTATION OF RIGHT LEG WAS DONE 6YRS AGO? IT #OF RIGHT FEMUR FOR WHICH SX WAS DONE WITH INSITE IMPLANT 2YRS AGO. AFTER THOROUGH CLINICAL EXAMINATION PT HAD ANASARCA, PITTING TYPE WITH DIFFUSE B/L CREPITATIONS IN BOTH LUNGS WITH VITALS BEING PR-103BPM, BP-
120/60MMHG, SP [O2-94@RA, GRBS-94MG/DL TEMP-102.6F AND NECESSARY
INVESTIGATIONS WERE SENT WITH ABG SHOWING PH-7.24, PCO2-23.7, PO2-94.6, SO2-
95.6, HCO3-10.0 AND PROVISIONALLY DIAGNOSED AS? CHF WITH ACUTE PULMONARY
EDEMA? LRTI? CAP? HYPOALBUMINEMIA, CELLULITIES OF B/L LOWER LIMB ANEMIA
SECONDARY TO? BLOOD LOSS AND PATIENT WAS STARTED ON CONSERVATIVE
MANAGEMENT WITH ANTIBIOTICS, DIURETICS AND OTHER SUPPORTIVE CARE. ON DAY 2 ANTIBIOTIC ESCALATION WAS DONE I/V/O RAISED TLC (AS PATIENT WAS TREATED
OUTSIDE FOR 4 DAYS). INJ.ALBUMIN WAS STARTED, KEPT ON INTERMITTENT CPAP WITH LOW PEEP-3, AS ASCITIC TAP (THERAPEUTIC) WAS DONE WHICH SHOWED ONLY
PROTEINECIOUS MATERIAL, NO CELLS SEEN.INJ GLYCOPYROLATE WAS ADDED.CT
ABDOMEN WITH CHEST SCREENING WAS DONE WHICH SHOWED B/L UPPER LOBES
GROUND GLASSING AND SEPTAL THICKENING OF BAT WINGS APPEARANCE? INFECTIVE? PULMONARY EDEMA, B/L LOWER LOBES COLLAPSED CONSOLIDATIONS AND MODERATE PLEURAL EFFUSION WITH SEVERE ANASARCA.
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AT AROUND 11PM PATIENT DEVELOPED TACHYCARDIA, TACHYPNEA AND FALL IN
SATURATION AND ABG SHOWED PH-6.94, PCO2-62.5,P O2-48.6, HCO3-13.0 AND EMERGENCY INTUBATION WAS DONE I/V/O FALLING SATURATION AND UNRESPONSIVENESS OF PATIENT. POST INTUBATION CONNECTED TO MECHANICAL VENTILLATORBUT PATIENT SATURATION DID NOT IMPROVE, DEVELOPED BRADYCARDIA WITH ABSENT PERIPHERAL AND CENTRAL PULSES FOR WHICH CPR WAS INITIATED ACCORDING TO ACLS GUIDELINES AND CONTINUED FOR 30 MIN DESPITE OF ALL RESCUCITATIVE EFFORTS PATIENT COULDNT BE REVIVED AND DECLARED DEATH ON 25/9/25 AT 12:40AM WITH ECG SHOWING FLAT LINE.
IMMEDIATE CAUSE: PULMONARY THROMBOEMBOLISM
TYPE II RESPIRATORY FAILURE
ANTECEDENT CAUSE: DECOMPENSATED CHF WITH ASCITIES PRECOX WITH PLUERAL EFFUSION AND PERICARDIAL EFFUSION
CELLULITIS OF B/L LOWER LIMBS? FILARIASIS
HYPOALBUMINEMIA, HYPOKALEMIA SECONDARY TO? DRUG INDUCED
Investigation
HEMOGRAM (23-09-25): HB-6.9, PCV-20.0, TLC-14500, RBC-2.61, PLT-2.26, PT-20SEC, APTT-
39SEC, INR-1.40
CUE:(23-9-25): ALB: NIL, SUG: NIL, RBC: NIL, PUS CELLS-2-3, EPITHELIAL CELLS:2-3,
RETICULOCYTE COUNT-1, T3-0.3, T4- 4.5, TSH- 1.29, S. FERRITIN-198, IRON-32, LDH-440
LFT (23-09-25): TB-0.63, DB-0.19, SGPT-38, SGOT-79, ALP-750, LFT (24-09-25): TB-0.51, DB-0.20, SGPT-39, SGOT-58, ALP-809 TP-3.5, ALB-1.0, AG RATIO-0.40
RFT (24-09-25): UR-27, CR-1.5, SODIUM-135, POTASSIUM-2.6, CHLORIDE-92
SEROLOGY (24-09-25): HIV, HCV, HBSAG- NEGATIVE, ASCITIC FLUID MICROSCOPIC
EXAMINATION: CYTOSMEAR STUDIED SHOWED ONLY PROTEINAECOUS MATERIAL, NO
CELLS SEEN, NO OPINION POSSIBLE
USG ABDOMEN AND PELVIS (23-09-25): IMPRESSION: GROSS ASCITIES, RASIED
ECHOGENICITY OF B/L KIDNEYS
2D ECHO (23-9-25): TACHYCARDIA, NO RWMA, TRIVAL AR/TR/MR; NO PAH; NO PR,
SCLEROTIC AV; NO AS/MS, EF 64% IVC SIZE 0.5CMS COLLAPSING NO LV CLOTS, GOOD LV
SYSTOLIC FUNCTION, GRADE1 DIASTOLIC FUNCTION, MINIMAL PE+AND PLEURAL
EFFUSION+
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HRCT CHEST (24-9-25): FINDINGS: B/L UPPER LOBE SHOWS GROUND GLASSING AND
SEPTAL THICKENING OF BATWINGS APPEARANCE? INFECTIVE? PULMONARY EDEMA, B/L LOWER LOBES COLLAPSED CONSOLIDATIONS AND MODERATE PLEURAL EFFUSION
SEVERE ANASARCA
CT SCAN ABDOMEN AND PELVIS (24-9-25): IMPRESSION: CHRONIC PANCREATITIS, GROSS ASCITES, B/L RENAL CALCULI, CHOLELITHIASIS, SEVERE ANASARCA
Treatment Given (Enter only Generic Name)
INTERMITENT CPAP, IVF DNS@ 50ML/HR, INJ PIPTAZ 2.25GM IV/TID --INJ MEROPENEM 1G
IV/BD, INJ CLINDAMYCIN 600MG IV/BD, INJ PAN 40 MG IV/OD, INJ LASIX 40MG IV/BD 8AM-X-
4PM, TAB PULMOCLEAR PO/BD, INJ IRON SUCROSE 2AMP IN 100 ML NS IV/OD ON
ALTERNATE DAYS, TAB THYRONORM 125 MCG PO/OD ON EMPTY STOMACH, TAB OROPFERXT
PO/OD X-1-X, NEB WITH IPRAVENT + BUDECORT+ MUCOMIST 6TH HRLY, LOWER LIMB
ELEVATION, REGULAR DRESSING, POSITION CHANGE 2ND HRLY, INJ.ALBUMIN 20%
IV/OD, INJ.GLYCOPYROLATE 0.2MG IV/BD, CHEST PHYSIOTHERAPY
Death Date
Date:25-9-25 Ward: ICU Unit:1
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