A 73 yr old male

Unit 3 admission 

http://sriramkk2k.blogspot.com/2021/08/case-of-74-year-old-male.html

ICU : 1st bed

A 74 yr old male, retired RTC driver(11 yrs back), resident of narketpally came to the casuality with

Complaints of

1.Fever since 3 days

2.Decreased urineoutput since 2 days

3.SOB GRADE : 3 since 1 day

HOPI

1.FEVER:

- Sudden in onset, associated with chills, incresed during nights &  relieved on medications.fever spikes increased after connecting urinebag before 2 days

2.DECREASED URINE OUTPUT:

- Normal frequency was 4 times/day & 3 times/night.since 2 days from tuesday morning, output decreased.they went to local RMP at night 10pm of tuesday  & urine bag was connected by local RMP.

3.SOB GRADE : 3 

- Present while walking & at rest also

PAST HISTORY:

- Pt was apparently asymptomatic 2 months back, was admitted & diagnosed in our hospital with lt facial nerve palsy, peripheral neuropathy(? ATT INDUCED), denovo HTN (? post pulmo tb),Spondyloarthropathy with radiculopathy sacroileitis cervical OPLL ( Ossification of posterior longitudinal ligament) - Ankylosing spondylitis

- k/c/o DM - 2 Since 20 yrs

PERSONAL HISTORY 

DIET: vegetarian 

APPETITE : decreased since 1 month

SLEEP: decreased since 2 days

BOWEL & BLADDER MOVEMENTS : urine  decreased

ADDICTIONS : smoking present since 20 yrs ( 3 packets/day ) stopped 5 yrs back

GENERAL EXAMINATION 

- NO Pallor, icterus, cyanosis,clubbing,lymphadenopathy,pedal edema

SYSTEMIC EXAMINATION 

CNS: FNAD

CVS: S1,S2 HEARD 

- No Murmurs

RESPIRATORY SYSTEM:

- NVBS

PERABDOMEN:

- Soft,tenderness & pain present

- abdominal distention: present

PROVISIONAL DIAGNOSIS:

- AKI (Prerenal/Renal)ON CKD k/c/o HTN/DM cervical spondylosis, ankylosing spondylosis.
altered sensorium secondary to metabolic (? Hepatic/uremic)

TREATMENT 

DAY : 0

1.IVF NS & RL @ 100ML/HR

2.INJ PIPTAZ 4.5 gm IV STAT

INJ PIPTAZ 2.25GM IV TID

  1_______X________1

3.INJ PAN 40 MG IV OD

 8AM _____X

4.INJ ZOFER 4MG/IV/SOS

5.INJ PCM 1GM IV SOS(IF TEMP >101°F)

6.INJ NORAD INFUSION( 2 AMP IN 46ML NS) @ 8ML/HR

7.BP CHARTING 2ND HRLY

8.TEMP/PR/BP CHARTING 2ND HRLY

9.INJ HAI SC (8AM__1PM___8PM)

10.GRBS CHARTING 6TH HRLY

( 8AM__1PM___8PM__2AM)

NEPHRO REFERRAL 

HEMOGRAM 

RBS

LFT

SERUM ELECTROLYTES 

SERUM CREATININE 

BLOOD UREA

2D ECHO 

ABG

CHEST X RAY

ECG AT 7:45 PM

AT 10:40 PM

AT 12:40 AM

DEATH SUMMARY:

A 70 yr old male, came to casualty with c/o SOB :1 DAY(GRADE 2 - 3) with pulse not palpable, BP not recordable.ABG showing metabolic acidosis.Bicarbonate correction was given.fluid resuscitation was planned.teople lumen catheter ionotropic support was started with noradrenaline, dobutamine titrated to requirement.Nephrology opinion was taken i/v/o increased urea & creatinine, dialysis was advised around 7 pm. CPR was initiated, Pt revived ABG showing severe metabolic acidosis.ventilator settings MODE: ACMV- VC, FiO2: 100%, PEEP: 5 cm H2O, V : 50 ml.Around 1:25AM pt became unresponsive.BP not recordable, pulse not palpable, CPR was initiated  according to AHA guidelines. Despite the above resuscitation efforts, pt could not be revived & declared dead on 22/10/21 @ 2:01AM 

IMMEDIATE CAUSE: -  Refractory hypotension, metabolic acidosis with type 1 respiratory failure

ANTECEDENT CAUSE:

- AKI(intrinsic) on CKD with metabolic encephalopathy (?Hepatic/uremic) post CPR status k/c/o T2 DM & HTN