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MORTALITY MEET

DR. NIKITHA SHIRINE TODETI

2^nd year postgraduate

DR.VIJAYA LAXMI

Assistant professor GM2

DEPARTMENT OF GENERAL MEDICINE

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Chief complaints

A 55 year old male, farmer by occupation came to casualty with

c/o Shortness of breath on walking for short distance since one week.
c/o B/L pedal edema since one week
c/o Abdominal distention with scrotal swelling since one week.

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Present history:

Pt was apparently asymptomatic one week back when he developed sob on walking for a short distance, which progressed to sob even at rest, following consumption of 180ml whiskey

a/w orthopnea ,
a/w wheeze
Not a/w with chest pain,
Not a/w cough,
Not a/w PND,
Not a/w palpitations
For which patient was admitted and treated in outside hospital with nebulisations on 2/02/2021.

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He also complained of abdominal distention which increased gradually,
a/w constipation which was relieved by soap water enema.
Not a/w pain, vomiting.

Followed by B/l pedal edema extending upto thigh, along with scrotal swelling,
Not a/w facial puffiness,
Not a/w with decreased urine output

He is not a k/c/o DM, HTN, CVA, CAD, TB, Epilepsy

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Past history:

Patient had similar complaints 6yrs back , when he first had sob on doing routine work, progressive, and was diagnosed as COPD, on intermittent nebulisations.

3 yrs back he was diagnosed with corpulmonale with severe PAH and has been on medication.
H/o abdominal distention and pedal edema for one year , for which he underwent therapeutic ascitic tap thrice before, the last one was done 3 months back.
H/O aggravation of symptoms on increased consumption of alcohol.

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Personal history:
Diet: mixed
Appetite : decreased
Bowel and bladder: constipation since 3 days
Sleep : disturbed due to orthopnea
Addictions : Chronic smoker for 30 years, one pack bidi/day.
Daily consumption of around 200 ml toddy/day and occasional consumption of 180ml whiskey.

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General Examination:
Pt. was thin built and poorly nourished
BMI:23.4kg/m2
Conscious, coherent, coperative, comfortable only in propped up position
Pallor: present
Icterus: absent
Cyanosis: absent
Clubbing: grade 1
Lymphadenopathy: absent
Edema: B/l pedal edema up to thigh, pitting type
Afebrile to touch

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Vitals:
RR: 24 cycles/min
PR: 84bpm, normal volume
BP: 120/70mmhg in sitting position
Spo2: 99%at room air
Grbs: 148mg/dl

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SYSTEMIC EXAMINATION:

Respiratory system:
Inspection :

Upper respiratory tract: normal

Lower respiratory tract:

B/l symmetrical, barrel shaped
Prominent sternocleidomastoid muscles on both sides
Type of breathing: thoraco-abdominal
Trachea appears central
No drooping of shoulders, no Supra clavicular hollowing or infraclavicular flattening
Respiratory movements appear equal on both sides.

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Palpation:
Position of trachea: central
Measurement: AP diameter= 42cm , transverse =37cm ,(ratio: 1:1 )
Chest expansion: 2cms
Respiratory movements :equal on both sides in all lobes
Vocal fremitus: normal
Percussion:
B/L hyper-resonant in all areas
Ausculatation:
B/L equal airway entry present
Normal vesicular breath sounds in all areas
Vocal resonance: normal

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Cardiovascular system:
Inspection : JVP raised up to angle of mandible in sitting position.

prominent v wave.

Pulsation visible in left parasternal area

No visible scars, dilated veins, sinuses, precordial bulge.

No epigastric pulsation

Apical impulse: not seen

Palpation:

JVP: measures 9cm 0f water from the sternal angle.

Apical impulse : not palpable.

Palpable P2 in Pulmonary area

Heave present in left parasternal area(grade 3)

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Auscultation:

Aortic area: S1 and S2heard

Pulmonary area: loud P2 ,Ejection systolic murmur heard (grade 2/6)

Aortic area: S1 and S2heard

Tricuspid area: Pansystolic murmur (Grade 6/6),increasing on inspiration

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Per Abdominal Examination
Inspection:

Distended, flanks appear full

Umbilicus : transversely stretched, centrally located

No dilated veins seen

Palpation:

Superficial: non tender, warm to touch

Deep: no organomegaly

Abdominal girth: 108cms

Perscussion:

Fluid thrill absent with presence of shifting dullness

Auscultation: bowel sounds present, no bruit heard.

CNS:HMF intact, no focal neurological deficit

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Provisional diagnosis:

K/c/o COPD with chronic corpulmonale with severe PAH

Investigations done:

Outside hospital:

CT pulmonary angiography: no evidence of chronic pulmonary embolism

RTPCR: negative

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ECG
rate:85 /min
rhythm: irregular
Axis: Right axis deviation
P wave present
Poor R wave progression

CXR P/A view:
The Lungs on either side show equal translucency
No focal Lung lesion is seen
The peripheral pulmonary vasculature is normal
The pleural spaces are normal
Both hila are normal in size, have equal density & bear normal relationship
The heart and trachea are central in position
Cardiothoracic ratio 0.6 S/O cardiomegaly

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On 2-2-2021

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INVESTIGATIONS

HEMOGRAM
HB = 5.6 gm/dl	Serum Iron = 84.5 ug/dl
TLC = 12,800 cells/cumm	Blood Group = O RH TYPING = Positive
PCV = 16.5 vol%	HBsAG = Negative
MCV = 102.7 fl	HIV ½ = Negative
MCH = 34.8 pg	Anti HCV Antibodies = Non Reactive
MCHC = 33.9 %
RBC = 1.61 million/cumm
PLT = 1.5 lakh/cumm
RBC = Anisocytosis with Hypochromic Microcytes,Macro ovalocytes,Few Pencil forms
Impression = Dimorphic Anemia with Leucocytosis

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RFT	CUE
Urea = 78———————— >95 mg/dl	Colour = Pale yellow
Creatinine = 1.5———— >2.2 mg/dl	Specific gravity = 1.010
Uric acid = 8.3 mg/dl	Albumin = Nil
Calcium = 9.8 mg/dl	Sugar = Nil
Phosphorus = 2.9 mg/dl	Bile salt = Nil
Sodium = 131 mEq/L	Bile Pigments = Nil
Potassium = 5.3 mEq/L	Pus cells = 2-4
Chloride = 98 mEq/L	Epithelial Cells = 1-2
	RBC = Nil
	Crystals = Nil Casts = Nil
	Amorphous deposit = Nil

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LFT
TB = 1.79 mg/dl	PT = 18
DB = 0.4 mg/dl	INR = 1.1
AST = 58 IU/L	APTT = 34
ALT = 50 IU/L
ALP = 346 IU/L
TP = 6.2 gm/dl
ALB = 3.1 gm/dl
A/G Ratio = 1.05

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Treatment on 2-2-2021
1) Propped up position	10) GRBS 8^th hrly
2) Fluid restriction <1.5lit/day	11) Abdominal Girth Monitoring
3) Salt restriction <2g/day	12) Plan for one unit of PRBC transfusion
4) Inj Lasix 40mg/IV/TID if SBP >110mmhg	13) Syp Lactulose 15ml H/S
5) Inj Monocef 1gm/IV/BD	14) Condomn Cathertisation
6) Inj Vit B12 1000mcg/IM/OD	15) Oxygenation to maintain Spo2 >=90%
7) Inj Pantop 40mg/IV/OD	16) Nebulisation with 2 Resipules of Budecort and asthalin stat
8) I/O charting	17) Inj Hydrocortisone 100mg/IV/Stat
9) BP,PR,TEMP charting hourly	18) Inj Deriphyllin 100mg / IV/ Stat

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At 6.00 pm on 2/02/2021,the patient’s saturation dropped to 87%at room air,

On auscultation :B/L Airway entry present with end expiratory wheeze present In all areas,

Nebulization with 2 resipules of budecort ,asthalin
Inj Hydrocortisone 100mg/IV/Stat was given
Inj Deriphyllin 100mg/IV/stat

Sp02 at room air was 94%following treatment

Diagnostic and therapeutic ascitic tap was done

Quantity:350ml,

Post procedure vitals :

Bp:90/60mmhg,

PR:87/min

RR:22cycles/min

Spo2:94%@room air

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Ascitic Fluid


Volume- 2.5ml	Sugar = 122 mg/dl	Ascitic fluid Cytology :- Negative for Malignancy
Appearance = Slightly cloudy	Protein = 2.1 g/dl
Colour = Pale yellow	LDH = 88 IU/L
Total Count = 60cells	Serum Albumin = 3.1 gm/dl
Differential count = 70% N+30%L	Ascitic Albumin = 1.2 gm/dl
RBC = Present	SAAG = 1.9
Other = Mesothelial Cells seen
ANALYSIS:HIGH SAAG ,HIGH PROTEIN	SUGGESTIVE OF CARDIAC CAUSES

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On 3/2/2021

The patient complained of tightness and burning sensation in epigastric area

O/E

Pt. was conscious, coherent, cooperative ,appeared tachpnoeic

Afebrile to touch

RR:29cycles/min

PR:106/min, normal volume

BP:140/90mmhg

Sp02:91%on room air

P/A:Tense, Non tender,BS:+,Girth:108 cm

R.S:BAE+, B/L end expiratory wheeze +in mammary, infra axillary and infrascapular areas

CVS: consistent with previous day

I/O:1570/550ml

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Treatment on 3-2-2021
1)Propped up position	10)Inj Pantop 40mg/IV/OD
2)Fluid restriction <1.5lit/day	11)I/O charting
3)Salt restriction <2gm/day	12)BP,PR,TEMP charting hourly
4) Nebulisation with 2 Resipules of Budecort 12^th hourly asthalin 8^th hourly	13)GRBS 8^th hrly
5)Inj Hydrocortisone 100mg/IV/BD	14)Abdominal Girth Monitoring
6)Inj Deriphyllin 100mg / IV/ BD	15)Plan for one unit of PRBC transfusion
7)Inj Lasix 40mg/IV/TID if SBP >110mmhg	16)Syp Lactulose 15ml H/S
8)Inj Monocef 1gm/IV/BD(day2)	17) Oxygenation to maintain Spo2 >=90%
9)Inj Vit B12 1000mcg/IM/OD

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At 11.30am

Pt Sp02 was 84 %on room air and 91 with 6lit Oxygen

RR:29cycles /min

Abg showing metabolic acidosis

Bicarbonate deficit: 440.4meq

Inj Sodium bicarbonate 100meq /slow IV /stat given

Inj Sodium bicarbonate 100meq in 50ml NS as infusion

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ABG(2-2-2021)	ABG(3-2-2021)
PH=7.40	PH=7.11
PCO2=26.7 mmHg	PCO2=17.1 mmHg
PO2 =76.7 mmHg	PO2 =28.1 mmHg
HCO3=16.4 mmol/L	HCO3=5.3 mmol/L
St.HCO3=18.6 mmol/L	St.HCO3=6.9 mmol/L
BEB = -7.0 mmol/L	BEB = -22.6 mmol/L
BEecf= -7.4 mmol/L	BEecf= -22.6 mmol/L
TCO2= 35.0 VOL	TCO2=12.5 VOL
02 Sat=70.5 %	02 Sat=26.5 %
	(venous sample)

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At 1.45pm, Pt was unresponsive

with SP02 :35%with 12lit O2,

PR:40/min, feeble,

BP: not recordable

Inj Atropine 1mg/IV/stat was given
Pt .was intubated with ET 6.5mm
Inj Noradrenaline 8mg in 50ml NS was started @6ml/hr
In view of no central pulses following intubation CPR was initiated according to 2015 AHA guidelines and 6cycles were done with rythm showing pulseless monomorphic VT , biphasic shock at 250J was administered, and CPR was continued for 2 more cycles
Inspire of all efforts the Pt. could not be revived and was declared dead at 2.35pm on 3/2/2021

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Immediate cause of death:

Cardiopulmonary arrest

Antecedent cause of death:

Acute Exacerbation of COPD with Corpulmonale with severe PAH(type 3)

Pre-renal AKI

Megaloblastic anaemia

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Time Line Events

6yrs(COPD)

Smoking(30years)

3yrs Corpulmonale with severe PAH

Abdominal Distension

Pedal edema

SOB(on walking)

SOB at Rest with orthopnea

SYMPTOMS

TIMELINE

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After Hospitalisation Day1	Day 2
S- SOB on lying down and at rest, abdominal distention	S- SOB decreased and then increased.
O- Saturation = 99% ------🡪89%------🡪▪94% with Neb	O- 91% on RA and 35% on 12lit oxygen.
A- Acute exacerbation of COPD with Corpulmonale with severe PAH type III Pre renal AKI Megaloblastic anemia	A- Acute exacerbation of COPD with corpulmonale with severe PAH type III Pre renal AKI Megaloblastic anemia Severe metabolic acidosis
P- Nebulisation with hydrocort, diuretics, asitic tap 350ml. �	P- Correct metabolic acidosis.