CONTINUOUS QUALITY
IMPROVEMENT
DURATION OF STAY –20 hours
Presenter-Dr. Sasi Ram
2nd year postgraduate
Department of General Medicine
CHIEF COMPLAINTS
A 65 years old man brought to er with a chief complaint
• Generalised weakness since 3 days
• Loose stools since 1 days
• Decreased urine output since 1 days
• Shortness of breath since 1 day
• Vomiting Since morning
History of presenting illness
• Patients was apparently normal 3 days back then patient
developed generalised weakness but able to do his routine
activities
• ℅ watery loose stools small quantity 2-3 episodes per day since
1 day non foul smelling not blood stained ,no mucous, No
worms in stool not associated with abdominal pain and Fever.
• ℅ shortness of breath insidious in onset progressed from grade
1 to 3 not associated with cough with expectation and chest
[Link] diurnal and postural variation
• ℅ decreased urine output since 1 day Not associated with
burning or change in colour of urine
• ℅ 2 episodes of vomiting which is non-bilious, non-projectile,
not blood stained and containing food particles with no history
of headache and blurring of vision
• No H/o pead edema ,Chest pain , palpitations ,Reeling
sensation.
• No H/o cough With expectoration,Hemoptysis,
• No h/o of black coloured stools and skin rash
• No H/o LOC, involuntary movements ,involuntary micturition
or defecation.
• He went to local hospital Day prior to admission they referred
to [Link]&RF I/V/O low platlets and elevated [Link]
Past medical history
H/o ? Urinary Bladder surgery ? mass removed 16 yrs back
DIABETES since 10 years on metformin 500 mg tab BID
HYPERTENSION of irregular medication since 10 yearson irregular
medication on Telmisartan 40 mg OD
Personal history
H/o Decreased appetite since 3 days
Patient is Ex smoker for 15 yrs and non-alcoholic.
Patient has normal bowel,Bladder and sleep habits
Patient has no known allergy to food or any medications
VITALS AT TIME OF ADMISSION
BP –100/70 mmHg
PR – 108 bpm
RR – 36 cpm
SpO2 – 94% RA 99% @4lit O2
TEMP – 99*F
GRBS-231 mg/dl
GCS- E3V4M5 12/15
GENERAL EXAMINATION
Patient was conscious, Irritable,tachypnic and confused
• No pallor
• No icterus
• No cyanosis
• No clubbing
• No lymphadenopathy
• Pedal edema Grade-1 pitting,slow filling +
• No oral patachae
• No blanching rash
• No eschar
• -ve hess test
SYSTEMIC EXAMINATION
CVS - S1 S2 heard, no murmurs
RS - B/L NVBS, with B/L decreased breath sounds in infrascapular and
infraaxillary areas
ABDOMEN - soft, distended, non-tender, Midline scar of 6 cm present
in lower abdomen below umbilicus + ,No organomegaly, normal bowel
sounds
CNS – B/L Pupils NSRL , No FND
B/L -plantar flexor
Other hosp labs:
HB 11.5 g/dl
WBC 9,300 cells/cumm
PLATELET 15 thousands
POLYMORPHS 89.1
MCV 83.7 fl
MCH 28.8 Pg
MCHC 34.4 gm/dL
LYMPHOCYTES 8.9
HCT 37.9
FBS 336 mg/dL
Creatinine serum 2.84 mg/dL
SERUM ELECTROLYTES
Sodium 133 meq/L
potassium 4.83 meq/L
chloride 100.5 meq/L
Provisional Diagnosis:
• Viral Gastroenteritis with thrombocytopenia
• ? AKI ,Uncontrolled Type-2 DM
• k/c/o T2DM, HTN
HB 11.4 gm%
TWBC 8.0 x10*3 cell
ESR 123 mm/hr
PCV 31.9%
PLATELET *10 x10*3/uL
MCV 84.7 fl
MCH 30.2 Pg
MCHC 35.7gm/dL
RDW-CV 14.9%
Smear Normocytic normochromic Anemia with
neutrophilic predominance
Thrombocytopenia
RFT On admission
Urea - serum 110 mg/dL
Creatinine serum 4.5 mg/dL
[Link] 8.6mg/dl
SERUM On admission VIRALS On admission
ELECTROLYTES
HIV NEGATIVE
Sodium 136 meq/L
HBsAg NEGATIVE
potassium 3.4 meq/L
HCV NEGATIVE
chloride 104 meq/L HbA1c 10.4%
TSH 2.0
ABG At time of admission
pH 7.330
pO2 79.3 mmHg
pCO2 19.3 mmHg
HCO3 13.8 mmol/ L
AG 18.2 (dGap-6.2)
Lactate 8.60 mmol/L
HAGmetabolic acidosis with
respiratory alkolosis,lactic acidosis
LFTS On admission
Total bilirubin 3.2 mg/dl
Direct 2.9 mg/dl
Indirect 0.3 mg/dl
Alkaline Phosphatase 359 U/Ⅰ
SGOT 53 U/L
SGPT 63 U/I
Total protein 5.5 g/dl
albumin 3.3 g/dl
globulin 2.2 g/dl
USG abdomen and pelvis
• IVC and hepatic veins prominent.
• Bilateral grade I renal parenchymal changes. Correlate
with RFT’s. Coagulation
• Tiny bilateral renal calculi.
PT 13.8
Dengue. -ve
aptt 36.0
paramax. -ve INR 1.2
MP,MF. -ve SOFA >12 95.4% mortality
LEPTOSPIROSIS -ve
SCRUB -ve
Treatment at time of admission
• IVF 2 unit NS bolus was given and then NS/RL @ 100 ml/hr
• NEBULIZATION DUOLIN AND BUDECOART 8 HRLY
• INJ DOXYCYCLINE 100 MG 12 HRLY 1-0-1
• INJ . METRONIDAZOLE 8th hrly 1–1-1
• INJ H ACTRAPID 8th hr1–1-1 (6u/8u/4u)
• INJ OFLOXACIN 200mg 12TH HRLY 1-0-1
• INJ ONDONSETRON 4mg 8TH HRLY 1-1-1
• TAB PARACETAMOL 650 MG SOS
• TAB LACTIC ACID BACILLUS 120M 8th hrly1–1-1
Nephrology referral I/V/o metabolic acidosis
BP-110/70 mmhg S. Creat- 4.5 mg/dl
Pr – 130 bpm S. urea- 110 mg/dl
RR- 36 cpm ABG- Metabolic acidosis with
sPO2- 98%@50%FiO2 respiratory alkolosis with lactic
acidosis
O/E
CVS- S1 S2 + ADVICE-
RS- b/l nvbs • With hold telamasrtan
P/A- soft, non tender • 2d echo
CNS- NFND • Hemodialysis if anuria for greater
than 12 hrs
2.5 hours after admission : patient become
unconcious,BP:80/60mmhg,spo2-80%@RA
ABG 2.5 hours after admission
pH 6.992
pO2 33.7 mmHg
pCO2 22.3 mmHg
HCO3 9.7 mmol/ L
Lactate 11.01 mmol/L
HAG metabolic acidosis with
respiratory alkalosis,Lactic acidosis
Neurology referral I/V/O Altered sensorium
BP- 80/60 mmhg on NORAD 4.5 mic
Pr – 120 bpm Diagnosis- Encephalopathy,
sPO2- 70% @RA, 98% @100% secondary to metabolic acidosis
FiO2 on Bipap ?viral ?GE,
GCS- E1V1M4
Advice
O/E- • EEG
Patient not responding to commands • Correct metabolic acidosis
S/E-
CVS- S1 S2 +
RS- , B/L Wheeze, basal crepts
CNS- B/L Pupils Sluggishly reactive,
B/L plantars Mute
3 hours after admission
BP- 80/60 mmhg on NORAD 5 mic/hr
Pr – 110 bpm
sPO2- 70% @RA, 98% @100% FiO2 on Diagnosis- Severe metabolic
Bipap acidosis, secondary to GE
GRBS- 176 mg/dl ?Prerenal AKI, ischemic ATN +
GCS- E1V1M1
Urine out put - NIL
Advice
O/E- • Plan for 2D ECHO
Patient not responding to commands • CST
S/E- • Bipap connected
CVS- S1 S2 + • Plan for HD, RDP and FFP
RS- B/L NVBS, B/L Wheeze, basal crepts • NaHco3 - 100 meq stat
CNS- B/L Pupils Sluggishly reactive, B/L
plantars Mute
OPTHALMOLOGY Opinion was taken
• Conjuctiva (N)
• Cornea (clear) RE LE
• AC (WNL)
MEDIA clear clear
• Pupil- pharmacologically dilated
OD (N) ;clear (N) ;clear
• Lens – IMSC
margins margins
CDR 0.3 0.3
IMPRESSION:
Bv Normal Normal
Both Eyes – Normal fundus
MACUL Normal Normal
A
FR + +
6 hrs Cardiology referral I/V/O IVC dilation in USG + SOB
BP- 100/70 mmhg on NORAD 7 mic
Pr – 120 bpm Findings –
sPO2- 70% @RA, 98% @100% FiO2 • FAIR LV SYSTOLIC
on Bipap FUNCTION(EF-50%)
GCS- E3V2M4 • Mild MR
• DILATED RA,RV
O/E-
• MILD TR; PAH
Patient is irritable
S/E- • GRADE I LV DD
CVS- S1 S2 + • IVC-DILATED & COLLAPSING
RS- B/L NVBS, B/L Wheeze, basal • NO CLOT/VEGETATIONS
crepts
CNS- B/L Pupils Sluggishly reactive,
B/L plantars Mute
6 hours after admission
Gcs E3V2M4 Central line was placed and 5
BP – 100/70 mmhg on NORAD 7 FFPS and 4 RDP transfusion
mic was done in timely manner
PR – 113 bpm
RR – 36 cpm
Temp – 98.6 F
SpO2 – 96% with 50%FiO2 on
Bipap
9 HOURS FROM ADMISSION
ABG 9 hours after admission
pH 7.314
pO2 107.7 mmHg
pCO2 21.6mmHg
HCO3 13.8mmol/ L
Lactate 8.28 mmol/L
HAG metabolic acidosis with
respiratory alkalosis,Lactic
acidosis
9 hours after admission
HEMODIALYSIS was started with dialysis with vitals
Pre HD vitals
BP- 110/70 on NORAD 12 Mic/hr
PR- 107 bpm
Duration - 4 hours (SLED) 7:00 to 11:00 PM
HEPARIN free HD done
17 hrs after admission patient suddenly desaturated on BIPAP
Death notes
19 November 2023
At 5:56 AM patient suddenly desaturated on BiPAP and 15 mic
NORAD , carotids not felt. Bp not recordable. Immediately high
quality CPR Started with Injection Adrenaline 1cc IV given.
Resuscitation continued according to ACLS Guidelines
Patient could not be revived and declared death at 06:26 AM on
19 November 2023
Cause of Death:
Sepsis with Multiorgan dysfunction syndrome
Known case of Type 2 Diabetes mellitus, hypertension
