45 male with SOB at rest

45 male with SOB @rest

HOPI-

Grampanchayat worker came to casualty with c/o SOB at rest since 4 days, anasarca since 4 months

Pt was apparently asymptomatic 2 years back and had h/o chronic alcohol intake- had sudden onset involuntary movements of b/l UL, LL lasted for 15 min and frothing from mouth with uprolling of eyes 

(+) with no post ictal confusion/involuntary micturition/defecation

Taken to a hospital where MRI was done and pt advised to stop taking Alcohol, started on T.Eptoin 100mg po/bd since then.

Then he had episodes of 5-6 since 2 years

4 months back, while he was lying on the bed, he had a seizure and fall from bed leading to fracture of right hip  

Then pt was taken to hospital and said to have low Hb and renal failure. 3 units PRBC tranfusion was done 4 months back and then pt developed pedal edema which was insidious in onset, gradually progressive to anasarca in 4 months

SOB- sudden onset, rapidly progressive with class 4(NYHA classification) with orthopnea and PND

N/c/k/o DM, HTN, BA, CAD, CVA

H/o TB 24 years back, ATT- 6 months

Alcohol addiction since 30 years, last alcohol intake 4 months back

No significant family history

O/E 

TEMP- afebrile

BP- 130/90 mmhg

Pr- 81 BPM

RR- 26CPM

SPO2- 100% at RA

GRBS- 166MG/DL

No icterus, cyanosis, clubbing, lymphedema

Moderate pallor present(+)

B/L pitting type of edema of feet (+) anasarca (+)

CVS- S1 S2 heard, JVP-N

RS- dyspnoe present, b/l crepts (+) in IAA, IMA, ISA

P/A- distended, free fluid (+), bowel sounds heard

CNS- NFND

PROVIONAL DIAGNOSIS-

AKI on CKD with Anemia 2° to CKD with Pulmonary Edema with Metabolic acidosis with seizure disorder with old Right Hip fracture

Dialysis one session done on 30/12/21

1 unit PRBC tranfusion done

Rx:

Fluid restriction <1.5 l/day

Salt restriction <2gm/day

Inj. Ceftriaxone 1gm iv bd

Inj. Lasix 80mg iv/stat--> 40mg iv/bd (8am--4pm--x)

Inj. PANTOP 40mg iv od

Inj.. ZOFER 4mg iv SOS

T. Nodosis 550mg po/bd

Cap Bio-D3 0.25 mcg po/od

T. Orofer-XT po/bd

T. Eptoin 100mg po/bd

Inj. Erythropoietin 4000iu s/c weekly once

Strict I/o charting

Vitals monitoring 4th hrly

1/1/22 

Soap Notes

S - sob reduced compared to yesterday

No fever spikes

O- Pt drowsy, but arousable 

Temp- 99f

Bp- 140/90mmhg

PR- 92bpm

RR- 22cpm

Spo2- 94% at ra

Rs-bae+

Cvs-s1s2+

P/a- soft, bs+

Cns- gcs E3V4M5

2 sessions of hemodialysis done 30/12(Ug 1.5lit), 31/12(Uf 2lit)

A- chronic renal disease with metabolic acidosis

Anemia sec to ? Chronic kidney disease

H/o seizure disorder

Old rt hip fracture

P-Fluid restriction <1.5lt / day

Inj lasix 40mg iv bd

Tab orofex xt po od

Inj erythropoietin 4000sc weekly once

I/o charting

Bp/PR /spo2 charting 4th hrly

3/1/22

DEATH SUMMARY

40/M came to casualty in the state of drowsiness but arousable with anasarca and SOB Grade-4. On presentation to casualty, patient was tachypnic with RR-40CPM, with B/L crepts (+) on all areas of lung fields with hypoxia. Immediately the pt was connected to oxygen and given Inj. Lasix 80mg iv stat, Inj. NTG 1mg in 4ml NS, 3ml IV/STAT given, ABG was done showing severe metabolic acidosis. pt was taken up for emergency dialysis with bood transfusion (as pt was had severe anemia) Pt underwent 3 sessions of dialysis. Dialysis sessions were uneventful. At 4am on 3/1/22, pt becmae unresponsive with fall in saturations adn BP not recordable. Pt was intubated. CPR was initiated and continued for 30 minutes. Despite all efforts, pt could not be revived and was declared dead on 3/1/22 at 4.25am with ECG showing no electrical activity

Immediate cause of death- CARDIO-PULMONARY ARREST SECONDAY TO PULMONARY EDEMA

Antecedent cause- CRF WITH ANEMIA SECONDARY TO CRF WITH METABOLIC ACIDOSIS WITH SEIZURE DISORDER WITH OLD RIGHT INTER-TROCHANTERIC FRACTURE(NON UNION)