Patient with SOB and pedal edema
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60 yr old female , resident of miryalguda , having 4 children. Pt used to work as ayamma in govt hospital. She stopped working 5 years ago due to jaundice and abdominal distension .
Pt is chronic alcoholic - 90-180 ml alcohol intake daily ( whiskey ), Non smoker .
History of one episode of seizures 8 yrs ago when they visited temple in yadgiri gutta - As she stopped alcohol bcoz she was going to temple. No other seizure episodes till date.
5 years ago pt had h/o abdominal distension ,and jaundice - she visited our hosp and got admitted . Records not available.
Was diagnosed to have ? Chronic liver disease.
She was on irregular medication since then.
2 yrs ago pt was again admitted in our hospital, in view of sob and pedal edema - she was diagnosed to have right heart failure and moderate pah and CLD and AKI .
pt had symptomatic relief and was discharged. Later after few days they visisted ,gandhi hospital for cardiologist opinion. There she was diagnosed to be RVD positive and was started on ART . But pt was not taking her medications regularly.
She was also told to have ? pneumonia / ? pericardial effusion .
She was diagnosed to have diabetes 2 yrs ago and is on glimi -m1 since then .
Not a k/c/o HTN ,TB ,ASTHMA ,CAD,CVA.
Pt still continues to drink daily . Stopped one week ago .
Since one month she had bilateral pedal edema , putting type extending upto knee .
Abdominal distension since 15 days
Facial puffiness since 15 days
Sob. since 1 week - grade 2 progressed to grade 4 sob since yesterday night .
H/o orthopnea present.
No h/o chest pain , decreased urine output.
No h/o previous surgeries/blood transfusions.
0/E : pt drowsy
BP- Not recordable.
PR - 130 bpm ; regular; feeble
RR - 35/ min
spo2 -78-82% on RA.
with bipap on fio2 100 % - 92%
CVS - s1s2 soft (? muffled )
RS - DECREASED bilateral air entry.
b/l diffuse crepts present.
No pallor , icterus present, pedal edema present.
Ascitis present.
Rasied jvp present.
Provisional diagnosis - ? Acute cor pulmonale with collapsed lv .
Rvd positive ( since 2 yrs)
Chronic liver disease.
k/co DM since 2 yrs).
? pericardial effusion.
? pulmonary embolism.
INVESTIGATIONS:
1) CBP:
2) CUE:
3) RFT:
Blood urea: 71 mg/dl.
Serum creatinine: 0.8 mg/dl.
Sodium: 125 mEq/dl.
Potassium: 3.9 mEq/dl.
Chloride: 95 mEq/dl.
4) D-DIMER: 10740 ng/ml.
5) TROPONIN-I: negative.
6) ABG:
PH: 7.32
PCO2: 21.3
PO2: 61.3
HCO3: 10.8
St.HCO3: 13.8
8) CHEST X-RAY:
Patient was admitted and shifted to icu , with ionotropes and bipap.
AS D-Dimers were elevated , she was started on thrombrolytics with INJ. STREPTOKINASE 2.5 Lakh IU infusion over 1 hour. , followed by 1 lakh IU infusion over 24 hours.
DEATH SUMMARY :
Date: 06/09/21
Ward: ICU
Unit: 4
Name of Treating Faculty:
DR.SOWMYA (INTERN),
DR.SUPRAJA (INTERN),
DR. LAKSHMAN (INTERN),
DR. AKSHARA (INTERN),
DR.PRAKASH (INTERN),
DR. ARUN (INTERN),
DR. RAVEEN (PGY2),
DR. NIKITHA (PGY3),
DR. K. VAISHNAVI (PGY3),
DR.ARJUN (AP),
DR.RAKESH BISWAS (HOD).
Diagnosis:
- ACUTE COR PULMONALE WITH MODERATE TO SEVERE PAH (SECONDARY TO ? ACUTE PULMONARY EMBOLISM? ) - - - MILD PERICARDIAL EFFUSION.
- CHRONIC LIVER DISEASE.
- K/C/O RVD SINCE 2 YRS.
- K/C/O DM II SINCE 2 YRS.
Case History and Clinical Findings:
60 yr old female , resident of miryalguda . Pt used to work as ayamma in govt hospital. She stopped working 5 years ago due to jaundice and abdominal distension .Pt is chronic alcoholic - 90-180 ml alcohol intake daily ( whiskey )Non smoker .History of one episode of seizures 8 yrs ago when they visited temple in yadgiri gutta - As she stopped alcohol bcoz she was going to temple. No other seizure episodes till date.5 years ago pt had h/o abdominal distension ,and jaundice - she visited our hosp and got admitted . Records not available.Was diagnosed to have ? Chronic liver disease.She was on irregular medication since then.2 yrs ago pt was again admitted in our hospital, in view of sob and pedal edema - she was diagnosed to have right heart failure and moderate pah and CLD and AKI .pt had symptomatic relief and was discharged. Later after few days they visisted ,gandhi hospital for cardiologist opinion. There she was diagnosed to be RVD positive and was started on ART . But pt was not taking her medications regularly.She was also told to have ? pneumonia / ? pericardial effusion .She was diagnosed to have diabetes 2 yrs ago and is on glimi -m1 since then .Not a k/c/o HTN ,TB ,ASTHMA ,CAD,CVA.Pt still continues to drink daily . Stopped one week ago .Since one month she had bilateral pedal edema , putting type extending upto knee .Abdominal distension since 15 daysFacial puffiness since 15 daysSob. since 1 week - grade 2 progressed to grade 4 sob since yesterday night .H/o orthopnea present.No h/o chest pain , decreased urine output.No h/o previous surgeries/blood transfusions.0/E : pt drowsyBP- Not recordable.PR - 130 bpm ; regular; feebleRR 35/ minspo2 -78-82% on RA.with bipap on fio2 100 % - 92%CVS - s1s2 soft (? muffled )RS DECREASED bilateral air entry.b/l diffuse crepts present.No pallor , icterus present, pedal edema present.Ascitis present.Rasied jvp present.
INVESTIGATIONS:
Hb A1c: 6.9.
RBS 203.
TROPONIN: NEGETIVE.
RFT:
SERUM ELECTROLYTES: NA- 125, K- 3.9, CL- 95.
SERUM CREATININE: 0.8 MG/DL.
BLOOD UREA: 71 MG/DL.
D-DIMER: 10740 NG/DL.
LFT:
TOTAL BILIRUBIN : 9.01 MG/DL.
DIRECT BILIRUBIN: 4.10 MG/DL. SGOT(AST) : 131 IU/L.
SGPT (ALT) : 43 IU/L.
ALKALINE PHOSPHATE: 491 IU/L.
TOTAL PROTEINS: 8.8 GM/DL.
ALBUMIN: 3.6 GM/DL.
A/G RATIO: 0.71 GM/DL.
Treatment Given:
1) INJ STRPTOKINASE 2.5 LAKH IU IV @ 8 ML/HR OVER 1 HOUR FOLLOWED BY INJ. STREPTOKINASE 1 LAKH IU ( 3 ML PER 1 HOUR OVER 24 HOURS).
2) INJ. HEPARIN 5000 IU IV Stat.
3) INJ. LASIX INUFUSION AT 1.5 - 2 ML/HR.
4) INJ. DOBUTAMINE @ 6 ML/HR.
5) INJ. NORADRENALINE 2 AMP IN 50 ML NS@14 ML/HR.
6) INJ. CEFTRIOXONE 1GM IV BD.
7) INJ. HAI S/C.
8) TAB ART PO/OD.
9) TAB UDILIV 300 MG RT/BD.
10) SYP. LACTULOSE 15 ML RT/BD.
11) BIPAP (INTERMITTENT).
12) BP/PR/RR/TEMP CHARTING HOURLY. 13) INJ THIAMINE 2 AMP IN 100 ML NS IV TID.
DEATH SUMMARY :
A 60 YR OLD FEMALE, PRESENTED TO CASUALTY YESTERDAY AFTERNOON WITH GRADE 4 SOB; B/L PEDAL EDEMA, ABDOMINAL DISTENSION AND FACIAL PUFFINESS. PATIENT WAS PREVIOUSLY DIAGNOSIS WITH CHRONIC LIVER DISEASE 5 YEARS AGO, AND ALSO WAS DIAGNOSISED WITH RIGHT HEART FAILURE AND MODERATE PAG 2 YEARS AGO. PATIENT WAS K/C/O RVD POSITIVE SINCE 2 YEARS ( ON IRREGULAR MEDICATION ) AND A K/C/O DM 2 SINCE 2 YEARS. PATIENT USED TO CONTINUE BING DRINKING AND DOESNT TAKE HER MEDICATIONS REGULARLY. PATIENT PRESENTED TO CASUALTY WITH GRADE 4 SOB.4 SINCE ADMISSION, HER BLOOD PRESSURE WAS NOT RECORDABLE AND CENTRAL PULSES ARE PRESENT BUT ARE FEEBLE. SP02 78% ON PRESENTATION, WHICH INCREASED TO 93 TO 95% WITH BIPAP AND HIGH FLOW OXYGEN. PATIENT WAS STARTED ON IONOTROPES ( NOR-ADRENALINE AND DOBUTAMINE), EVEN WITH MAXIMUM DOSES HER BLOOD PRESSURE WAS'NT RECORDABLE. WE DID 2D-ECHO AND ECG AND OTHER ROUTINE INVESTIGATIONS. 2D- ECHO WAS SHOING GROSS DILATED RA AND RV WITH SHIFTING OF IVS AND D- SHAPED VENTRICLE AND SEVERE PAH AND MILD TO MODERATE PERCARDIAL EFFUSION. PATIENT WAS DIAGNOSISED AS 'ACUTE COR PULMONARY ' WITH SECURE PAH SECONDARY TO ? ACUTE PULMONARY EMBOLISM. CHRONIC LIVER DISEASE. MILD MODERATE PERICARDIAL EFFUSION AND K/C/O RVD POSITIVE AND K/C/O DM 2. PATIENT D-DIMER WERE ALSO VERY HIGH (10,740). PATIENT WAS STARTED ON INJ.STREPTOKINASE 2.5 LAKH IU FOLLOWED BY INFUSION OF 1 LAKH IU OVER 1 HOUR. PATIENT WAS MENTIONED OVER NIGHT WITH ALL SUPPORTIVE TREATMENT. INSPITE OF ALL NECESSARY TREATMENT AND IONOTROPIC SUPPORT, PATIENT BLOOD PRESSURE DIDNT OMPROVE ON 6/9/21 @ 2:45PM IN VIEW OF ABSENT PULSE, CPR WAS STARTED ACCORDINGLY TO AHA GUIDLINES AND CONTINUED. DESPITE OF ABOVE RESUSCITABLE MEASURES, PATIENT COULDNT BE REVIVED AND DECLARED DEAD ON 6/9/21 @3:15PM IMMEDIATE CAUSE OF DEATH: ACUTE COR-PULMONALE WITH SEVERE PAH SECORDARY TO ACUTE PULMONARY EMBOLISM. ANTECEDENT CAUSE OF DEATH: MILD-MODERATE PERCARDIAL EFFUSION, CHRONIC LIVER DISEASE, RVD POSITIVE, K/C/O - DM 2
