CONTINUOUS QUALITY

IMPROVEMENT

DURATION OF STAY - 9 days

PRESENTATOR – Dr. Venkat Nikhil

2nd year Post Graduate
Department of General Medicine
 CHIEF COMPLAINTS
A 72 year old male was brought to ER with chief
complaints of
● Abdominal pain since 1 day.
● Vomitings since 2 days.
● Bilateral lower limb swelling and decreased urine
output since 2 days .
● Shortness of breath since 10 days
 HISTORY OF PRESENT ILLNESS
● Patient was apparently normal 10 days back after which
presenting complaints started asC/o Shortness of breath
which is insidious in onset since 10 days , progressed from
grade 3 to grade 4, associated with PND.

● C/o vomitings since 2 days- insidious in onset,6 episodes per

day ,bilious, non-projectile contains food particles,non blood
tinged,non foul smelling.

● C/o abdominal pain since 1 day insidious in onset,gradually

progressive, diffuse,non radiating ,aggravated on food intake.
● No C/o cough, cold, fever
● No c/o chest pain ,palpitations
● No c/o burning micturition, increase or decrease in
frequency of micturition, loose stools,melena, black
coloured stools.
PAST HISTORY
● No history of similar complaints in the past.
● K/c/o DCMP since 1 year on medications
● H/o trauma to left ankle- debridement done 1 year
back.
● H/o usage of native medication for 2 years for lower
limb wound.
● k/c/o T2DM – not on regular medication
● NOT A K/C/O HTN,CVD,CKD
PERSONAL HISTORY
● Mixed diet
● Regular bowel and bladder habits
● Known smoker and alcoholic since 30 years

Family history
Nil significant
 General condition on examination
Patient is on sedation and mechanical ventilation
Well built and nourished.
• Icterus +
• No Pallor
• No cyanosis
• No clubbing
• No lymphadenopathy
• Edema- bilateral,pitting pedal edema , grade-3
 Vitals at the time of presentation
BP-Not recordable
PR-138/min
RR-26/min
SPO2-77% with 15 litres oxygen
Temp-Afebrile
GRBS- 56mg/dl- 87 mg/dl ( after25% dextrose IV infusion)
 I/v/o Poor GCS,decreased saturation ,
patient got intubated on day of admission
in ER
Pre intubation Post intubation
Vitals: Vitals:
• Temp-afebrile
• Temp: afebrile • PR-95 bpm
• BP-non-recordable
• RR-32 cpm
• PR: 74/min
• Spo2-100%wtih 100%fio2
• Bp: Non-recordable
ABDOMEN – SYSTEMIC EXAMINATION
Inspection
Shape of the abdomen : flat
Umbilicus : central and inverted
All quadrants are moving equally with respiration
No scars / no sinus / engorged veins
Palpation
No local rise of temperature
Diffuse tenderness present on superficial
palpation –wincing present
Guarding present
Rigidity absent
No hepatomegaly
No splenomegaly
Percussion
• No fluid thrill
• No shifting dullnes

Auscultation
• Bowel sounds absent
CVS:
• S1,S2 heard
• No murmurs

CNS:
• GCS- E3 V1 M3 ( 7/15)
• B/L Pupils- B/L NSRL
• Plantars – B/L flexors

RS :
• BILATERAL BASAL COARSE CREPITATIONS PRESENT
Provisional diagnosis
• SEPTIC SHOCK WITH MULTI ORGAN DYSFUNCTION
• k/c/o DCMP,TYPE-2 DIABETES MELLITUS
• HYPOGLYCEMIA SECONDARY TO ? SEPSIS
Investigations at admission
 CBP At time of admission
HB 7.1
FDP >800mcg/ml
WBC 27,800
DC N96,L1,E0,M5,B0

PLATELETS 2,30,00
MCV 75.5
MCH 23.9 D-Dimer 8.28 ng/ml
MCHC 31.7
ESR 16
IMPRESSION MICROCYTIC
HYPOCHROMIC
ANEMIA
 Serum At time of RFT At time of
Electrolytes admission admission

Na 134 Urea 118

K 5.2
Creatinine 3.7
Cl 101
 LFT At time of admission
Total Bilirubin 5.4
Direct Bilirubin 3.4 PT More than
2 minutes
Indirect Bilirubin 2.0
Alkaline Phosphate 146

Aspartate 278 Hba1c 7.6%

Transaminase
Alanine Transaminase 229

Total protein serum 6.8

TSH 4.67 MIU/L
Albumin serum 4.3
Globulin serum 2.6
A/G ratio 1.6:1
 ABG At time of
admission CUE At time of
PH 7.324 admission
Protein Negative
PO2 108.0
Ketones Negative
PCO2 38.6
HCO3 18.6 Glucose Negative

Lactate 1.98 Hb Negative

IMPRESSION HAGMA
Leukocytes Negative
ECG
Chest X-ray:
X RAY SUPINE ABDOMEN
LATERAL DECUBITUS X RAY
USG ABDOMEN AND PELVIS

• Altered hepatic parenchymal echotexture- correlate with

LFTS.
• Prominent IVC and hepatic veins to rule out cardiac
failure – suggested 2D echo correlation.
Bilateral increased renal parenchymal echotexture-
correlate with RFTs.
• Moderate fluid with internal echos seen in abdomen seen
in abdomen and pelvis –ascites.
• Moderate bilateral pleural effusion.
• Thickened and edematous gallbladder wall.
 2D ECHO
• Dilated all chambers
• EF-35%
• Global hypokinesia of LV with moderate LV systolic dysfunction
• RV dysfunction present
• Moderate TR/PAH
• RVSP-35 mmhg
• IVC dilated,not collapsing
• NO PE/Clots/vegetations.
Treatment at time of presentation
● INJ.PIPTAZ 2.25 gm IV TID
● INJ.METROGYL 500 mg IV TID
● IV FLUID – NS @50ML/HR
● INJ.PANTOPRAZOLE 40 mg IV OD
● INJ.NORADRENALINE titrated according to BP
● IV FLUID 25% DEXTROSE IF GRBS <75 mg/dl
● INJ. DOBUTAMINE IV INFUSION TITRATED
ACCORDING TO BP
● Fluids LESS THAN 1 litre/day
SURGERY REFERRAL
• REFERRED I/V/O pain abdomen , non-healing ulcer over left
lower limb
• Advised :
• Left lower limb arterio-venous Doppler
• Regular dressing
• Continue same treatment
 Day -2
Vitals :
Temp-Afebrile
BP- 80/60 mmhg on monitor WITH
3 INOTROPES
PR-101 bpm VASOPRESSIN IV
INFUSION WAS ADDED
RR-21 cpm
SpO2-98% @ 100% fio2 REST OF THE
Gcs-E4VTM4 TREATMENT WAS
CONTINUED
I/O-500/580ml
Grbs-111 mg/dl
Stools not passed
P/A- DISTENDED,GUARDING
present , bowel sounds ABSENT
 CBP Day 2
HB 7.1
RFT Day 2
WBC 27,400
DC N94,L1,E0,M5,B
0
PLATELETS 2,30,00 Urea 119
MCV 75.5
MCH 23.9
MCHC 31.7 Creatinine 3.7
ESR 16
IMPRESSION MICROCYTIC
HYPOCHROMIC
ANEMIA
 LFT Day 2
Total Bilirubin 4.2
Direct Bilirubin 3.4 PT 53.8
Indirect Bilirubin 0.8
Alkaline Phosphate 120
INR 4.6
Aspartate 233
Transaminase
Alanine Transaminase 450 APTT 42.5
Total protein serum 5.2
Albumin serum 3.2
Globulin serum 2.6
A/G ratio 1.6:1
 ABG Day 2 Serum Day 2
Electrolytes
PH 7.256
Na 134
PO2 114.0
K 5.7
PCO2 42.0
Cl 101
HCO3 19.4
Lactate 1.86 Mg 1.3

IMPRESSION HAGMA CORRECTED 8.4

Ca
SURGERY REVIEW REFERRAL
• CASE WAS REVIEWED- O/E : ABDOMEN APPEARS DISTENDED ,GUARDING
PRESENT, Pt WHINCING ON PALPATION – RIGHT HYPOCHONDRIUM> RIGHT
LUMBAR> RIGHT ILIAC FOSSA> LEFT SIDE OF ABDOMEN , RIGIDITY ABSENT,
BOWEL SOUNDS ABSENT
• DIAGNOSIS -? ACALCULOUS CHOLECYSTITIS ,? CONGESTIVE
HEPATITIS
• ADVISED CT ABDOMEN AND PELVIS AND REVIEW
• CT WAS REVIEWED AND ADVISED SURGICAL INTERVENTION - BUT PATIENT
ATTENDERS ARE NOT WILLING FOR SURGERY
• ULTRASOUND GUIDED ASCITIC TAP WAS DONE AND FLUID ANALYSIS WAS
SENT
CT ABDOMEN
• Moderate ascites
• Bilateral pleural effusion with atelectasis of the underlying basal
segments
• Pneumothorax on right side
• Small pockets of free air in the peritoneal cavity- this could be
secondary to pneumothorax/ hollow viscus injury
• Left indirect inguinal hernia
• Cardiomegaly
PERITONEAL FLUID ANALYSIS
Sugar 70
Malignant cells Negative
Acid fast bacilli Negative
Culture and sensitivity No bacterial growth

Cell count 25,000

Neutrophils 95%
Lymphocytes 5%
RBC Positive
PULMONOLOGY REFERRAL
• I/v/o right sided pneumothorax
• Advised:- ICD insertion
• 24 F ICD TUBE IS INSERTED INTO RIGHT 4TH INTERCOASTAL
SPACE IN ANTEROAXILLARY LINE – 50 ml of serosanguinous
fluid and gush of air was drained .
• Advised inj. Tramadol SOS, ICD care , rest CST .
CHEST X RAY POST ICD INSERTION
VITALS:
DAY 3
TEMP-Afebrile
PR- 106 bpm • 1 UNIT PACKED RBC
BP-NOT RECORDABLE ( 80/60 TRANSFUSION WAS DONE.
mmHg on monitor ) With 3
inotropes • 4 UNITS FFP TRANSFUSION
RR-26 cpm WAS DONE I/V/O
Spo2-96%@40% fio2 DERANGED PT/INR.
Gcs-E2VTM5 • ICD CARE WAS GIVEN.
I/o-1710/1050 ml
Grbs-142 mg/dl • REST OF THE TREATMENT
P/A - DISTENDED, DIFFUSE WAS CONTINUED.
TENDERNESS , BOWEL SOUNDS
ABSENT
 CBP Day 3
RFT Day 3
HB 6.6
WBC 12,800
DC N96,L1,E0,M5,B0 Urea 133
PLATELETS 2,30,00
MCV 75.5
MCH 24.4 Creatinine 3.1
MCHC 31.7
ESR 16
IMPRESSION MICROCYTIC
HYPOCHROMIC SOBT Positive
ANEMIA
 LFT Day 3 PT 36.9
Total Bilirubin 5.0
Direct Bilirubin 3.9 APTT 39.1
Indirect Bilirubin 1.1
Alkaline Phosphate 99 INR 3.2

Aspartate 570 After

Transaminase transfusion of
Alanine Transaminase 422 4 FFPS
PT 42.6
Total protein serum 6.1
Albumin serum 3.8 APTT 31.6
Globulin serum 2.3 INR 3.7
A/G ratio 1.6:1
 ABG Day 3
Serum Day3
PH 7.247 Electrolytes

PO2 105.0

PCO2 40.1
Na 137
HCO3 16.8
K 5.2
Lactate 1.94

IMPRESSION HAGMA Cl 105

Cultures Day 3

Blood Negative

Urine Escherichia coli>1,00,000 CFU/ML

VITALS: DAY 4
TEMP-Afebrile
PR- 106 bpm
Bp- NOT RECORDABLE ( 90/70
MMHG ON MONITOR) ON 3 1 unit PRBC
INOTROPES
RR-16 cpm transfusion wasdone
Spo2-100%@40% fio2 Rest of the treatment
GCS-E3VTM6 was continued
I/O-2000/925 ml
Grbs-142 mg/dl
Stools -passed
P/A- soft,tenderness present
diffusely bowel sounds not heard
REVIEW SURGERY REFERRAL
O/E-Abdomen –distended, tenderness present illicited on wincing
diffusely all over abdomen ,guarding present , bowel sounds absent,
rigidity and fluid thrill was absent.
Advised :
• Continuous Ryle’s drainage
• 5 FFPs transfusion
• Inj. Vitamin –K 10mg IM OD
• ABDOMINAL GIRTH monitoring second hourly
• Gastroenterology referral i/v/o MRCP to R/O cholangitis and CBD
pathology .
PULMONOLOGY REVIEW REFERRAL
• 100 ml of serosanguinous fluid collected
• Tube patent
• Column movement present
• No bronchopleural fistula / soakage

Advised:-
• ICD care
• Send for pleural fluid ADA,LDH,CELL COUNT,MALIGNANT
CELLS,C/S,AFB,KOH,cell block ,CBNAAT,LDH
PLEURAL FLUID ANALYSIS
Protein 0.5
Glucose 27
ADA 5.6
LDH 216
Shows predominant
Cell block study polymorphism,
lymphocytes and areas of
hemorrhage,no malignancy
seen
Acid fast Negative
KoH mount Negative
Gram strain Negative
 CBP DAY -4
HB 8.3 RFT DAY-4
WBC 12,100
DC N96,L1,E0,M5,B Urea 147
0
PLATELETS 1,50,000
MCV 76.9 Creatinine 2.9
MCH 25.9
MCHC 31.7
ESR 24
IMPRESSION MICROCYTIC
HYPOCHROMIC
ANEMIA
 LFT DAY-4 PT 63.2
Total Bilirubin 5.4
Direct Bilirubin 3.4 APTT 34.5
Indirect Bilirubin 2.0
Alkaline Phosphate 146 INR 5.4

Aspartate Transaminase 278

After
transfusion of
Alanine Transaminase 229 FFP

Total protein serum 6.8 PT 42.6

Albumin serum 4.3
APTT 31.6
Globulin serum 2.6
INR 3.7
A/G ratio 1.6:1
 ABG Day 4
PH 7.269 Serum Day 4
Electrolytes

PO2 134.2
PCO2 32.1
Na 138
HCO3 17.5
K 5.5
Lactate 1.69
IMPRESSION HAGMA Cl 101
VITALS:
DAY 5
TEMP-Afebrile
PR- 102 bpm
Bp-100/70 mmhg (ON 2 UNITS FFP’S
MONITOR )WITH DUAL TRANSFUSION WAS GIVEN.
INOTROPES 1 UNIT PRBC TRANSFUSION
RR-26 cpm WAS DONE
Spo2-100%@35% fio2 INOTROPES WERE TAPERED
GCS-E3VTM6
I/o-1954/695 ml REST OF THE TREATMENT
Grbs-177 mg/dl WAS CONTINUED
Stools -passed
P/A- soft,tenderness present
diffusely ,bowel sounds absent
CARDIOLOGY REVIEW REFERRAL
2D ECHO:
• All dilated chambers
• EF-25%
• Global hypokinesia of LV
• Severe TR/PAH
• Moderate MR
• RVSP-27 mmhg
• IVC dilated,not collapsing
SURGERY REVIEW REFERRAL
• P/A- DISTENDED , TENDERNESS PRESNT ALLMOVER ABDOMEN
DIFFUSELY ,GUARDING PRESENT, BOWEL SOUNDS ABSENT
• PATIENT ATTENDERS WERE EXPLAINED ABOUT NEED FOR SURGICAL
INTER VENTION I/V/O ANY INTRA ABDOMINAL PATHOLOGY , RISKS
INVOLVED IN SURGERY AND ANAESTHSIA WERE EXPLAINED – BUT
PATIENT ATTENDERS ARE NOT WILLING AND WANTS TIME TO DECIDE.
PULMONOLOGY REVIEW REFERRAL
• ICD- TUBE PATENT ,COLUMN MOVEMENT PRESENT , 80-100ML FLUID
COLLECTED .
• IMPRESSION – REACTIVE EFFUSION
• ADVISE: SEND SERUM LDH, PLEURAL FLUID CBNAAT , ICD CARE.
 CBP DAY-5
HB 10.0
WBC 12,800
DC N96,L1,E0,M5,B0 RFT DAY-5

PLATELETS 2,39,000
Urea 133
MCV 75.9
MCH 24.4
MCHC 32.2 Creatinine 3.1
ESR 30
IMPRESSION MICROCYTIC
HYPOCHROMIC
ANEMIA
 LFT DAY-5
Total Bilirubin 7.3 PT 47.4
Direct Bilirubin 6.7
Indirect Bilirubin 1.3
Alkaline Phosphate 99
ApTT 54.4
Aspartate Transaminase 230

Alanine Transaminase 222

INR 4.32
Total protein serum 6.1
Albumin serum 3.7
Globulin serum 2.3
A/G ratio 1 .6:1
 ABG DAY-5
PH 7.329
Serum DAY-5
Electrolytes
PO2 82.5
Na 138
PCO2 35.7
HCO3 18.8 K 5.5

Lactate 1.68 Cl 101

IMPRESSION HAGMA
VITALS:
DAY -6
TEMP-Afebrile
PR- 98 bpm 4 unit FFPs transfusion
Bp-110/70 mmhg on monitor ( with was done
DUAL INOTROPES) INOTROPES were
RR-24 cpm tapered .
Spo2-100%@35% fio2 Rest of the treatment
Gcs-E3VTM6 was continued.
I/o-1400/920 ml
Grbs-178mg/dl
Stools- passed
P/A- soft,tenderness present diffusely
bowel sounds absent.
Review USG abdomen and pelvis
• Compare to previous USG
• There is decrease in pleural effusion and ascites
component,however
Mild b/l pleural effusion and Mild ascites,with free floating
echoes .
 CBP DAY-6
RFT DAY-6
HB 11.4
WBC 8.7
DC N96,L1,E0,M5,B0 Urea 146
PLATELETS 1,80,000
MCV 76.9 Creatinine 3.9
MCH 75.1
MCHC 32.7
ESR 35
IMPRESSION MICROCYTIC
HYPOCHROMIC
ANEMIA
 LFT DAY-6
Total Bilirubin 11.4
Direct Bilirubin 8.7
Indirect Bilirubin 2.7
PT 35.0
Alkaline Phosphate 98

Aspartate 124
Transaminase
Alanine Transaminase 155
Aptt 50.1

Total protein serum 5.9

Albumin serum 3.4
INR 3.0
Globulin serum 2.5
A/G ratio 1.3:1
 ABG DAY-6
PH 7.352 Serum DAY-6
Electrolytes
PO2 82.5
PCO2 35.7
Na 137
HCO3 18.8
K 5.3
Lactate 1.68
IMPRESSION HAGMA Cl 104
 DAY-7
VITALS:
TEMP-Afebrile
PR- 106 bpm
Bp-110/70 mmhg (on monitor with 2 units of FFPs transfusion was
dual inotropes .) done
RR-16 cpm
Spo2-100%@35% fio2 Inj. 25% DEXTROSE IV infusion
Gcs-E3VTM6 @5ml/hr titrated according to
I/o-1799/910 ml grbs to prevent hypoglycemia
Grbs- 64 mg/dl -178mg/dl( after
giving 25 % D infusion ) Rest of the treatment was
Stools not passed continued
P/A- soft,tenderness present diffusely,
bowel sounds not heard
Surgery (case reviewed)
Advised:-
• Medical gastroenterology referral
• X-ray supine abdomen
• Bilateral peritoneal tap
• Review with reports
Procedure notes
• Under LA,SAP, parts painted with betadine ,a skin incision
made in right and left spinoumbilical line at 4cm above ASIS.
Incision deepened in layers with straight long artery forceps
and loss of resistance felt after peritoneal breach . Straw
coloured fluid of about 50 cc left side , 20cc right side drained
and ADK TUBE INSERTED INTO PERITONEAL CAVITY AND
FIXED TO SKIN . PATIENT IS HEMODYNAMICALLY STABLE
THROUGHOUT ND AFTER POCEDURE , STERILE DRESSING
DONE
PERITONEAL DRAIN
PERITONEAL DRAIN
X R A Y S U P IN E A B D O M E N
MEDICAL GASTROENTEROLOGY
REFERRAL
• ADVISED:
• Ascitic fluid albumin, TC,DC,Amylase , bilirubin, glucose, LDH
• ? CONGESTIVE HEPATOPATHY .
Ascitic fluid Analysis
Glucose 77 70-140 mg/dl
Protein 2.4 0.3-4.0 mg/dl

ADA 29.0 <30 mg/dl

LDH 1037 230-460 mg/dl
Total bilirubin 4.6 0-2 mg/dl
Direct bilirubin 3.0 0-0.2 mg/dl
Amylase 44 28-100 U/L
Albumin 1.3 3.5-5.5g/dl
 Cell count 500

Neutrophils 80%

Lymphocytes 20%

Other cells Reactive Mesothelial cells

Sediment cytology Reactive Effusion with acute

inflammation
 CBP DAY-7
HB 9.3
WBC 12,000
DC N96,L1,E0,M5,B0 RFT DAY-7

PLATELETS 2,00,000
Urea 190
MCV 81.5
MCH 32 .2
MCHC 32.4 Creatinine 2.2
ESR 30
IMPRESSION MICROCYTIC
HYPOCHROMIC
ANEMIA
 LFT DAY-7
Total Bilirubin 11.6
Direct Bilirubin 8.8
Indirect Bilirubin 2.8
Alkaline Phosphate 91
PT 47.4

Aspartate 122
Transaminase Aptt 54.4
Alanine 150
Transaminase
Total protein serum 5.4 INR 4.12
Albumin serum 3.4
Globulin serum 2.5
A/G ratio 1.3:1
 ABG DAY-7
PH 7.452 Serum DAY-7
Electrolytes
PO2 83.7
PCO2 29.3
Na 144
HCO3 21.4
Lactate 1.68 K 4.8

IMPRESSION METABOLIC Cl 101

ALKALOSIS
VITALS: DAY-8
TEMP-Afebrile
PR- 101 bpm
Bp-100/60 mmhg ( on monitor) with Dual
inotropes Inj.LASIX 40 mg in 36 ml
RR-17 cpm
Spo2-100%@35% fio2 NS infusion @1ml/hr
GCS-E3VTM5 REST of the treatment
I/o-1300/900 ml was continued
Grbs-95mg/dl
Stools -not passed
Rt peritoneal drain -30 ml
Lt peritoneal drain-220 ml
P/A- soft,tenderness present diffusely ,bowel
sounds heard
SURGERY REVIEW REFERRAL
• Continue same treatment
• Protein supplementation.
MEDICAL GASTROENTEROLOGY
REVIEW REFERRAL
• DIAGNOSIS : DCMP WITH SEVERE LV DYSFUNCTION , SECONDARY
BACTERIAL PERITONITIS ? NON OCCLUSIVE MESENTERIC ISCHAEMIA
• PLAN : CT-ANGIO ABDOMEN
 CBP DAY-8
HB 9.3
WBC 11,009
DC N96,L1,E0,M5,B0
RFT DAY-8
PLATELETS 1,50,000
MCV 78.9 Urea 184
MCH 32.7
MCHC 32.6 Creatinine 2.0
ESR 35
IMPRESSION MICROCYTIC
HYPOCHROMIC
ANEMIA
 LFT DAY-8
Total Bilirubin 12.0
PT 43.9
Direct Bilirubin 8.7
Indirect Bilirubin 3.3
Alkaline Phosphate 82
Aptt 73.9
Aspartate 84
Transaminase
Alanine 107
Transaminase
Total protein serum 5.4
INR 3.8
Albumin serum 3.0
Globulin serum 2.4
A/G ratio 1.2:1
 ABG DAY-8
Serum DAY-8
PH 7.335 Electrolytes
PO2 42.8
PCO2 41.1 Na 146
HCO3 21.0
Lactate 2.06 K 4.9
IMPRESSION HAGMA
Cl 101
VITALS: Day-9
TEMP-Afebrile
PR- 86 bpm
Bp-100/60 mmhg( on monitor ) with
dual inotropes Inj.MEROPENEM 500 mg IV
RR-17 cpm BD
Spo2-100%@35% fio2 INJ.CLINDAMYCIN 600 mg IV
GCS-E3VTM6
I/o-913/1380 ml TID
Grbs-96mg/dl Rest of the treatment was
Stools not passed continued
Rt peritoneal Drain-10 ml
Lt peritoneal drain-25 mL
P/A- soft,tenderness present diffusely
bowel sounds not heard
CHEST X RAY
SURGERY REVIEW REFERRAL
• CONTINUE YOUR LINE OF MANAGEMENT
• REVIEW SOS
PULMONOLOGY REVIEW REFERRAL
• ICD-TUBE PATENT, COLUMN MOVEMENT PRESENT, 300 ML OF
SEROSANGUINOUS FLUID COLLECTED
• ADVISED: NEBULISATION WITH FORACORT 1MG BD
ENT REFERRAL
• REFEERED I/V/O TRACHEOSTOMY
• ADVISED: SEND BT,CT,HIGH RISK CONSENT , CONSENT FOR
TRACHEOSTOMY, REVIEW WITH CONSENT AND REPORT .
 CBP DAY-9
HB 9.1
WBC 11,ooo
DC N96,L1,E0,M5,B0
PLATELETS 1,50,000 RFT DAY-9
MCV 78.5
MCH 33.2 Urea 189
MCHC 33.2
ESR 26 Creatinine 1.8
IMPRESSION MICROCYTIC
HYPOCHROMIC
ANEMIA
 LFT DAY-9
Total Bilirubin 12.8
Direct Bilirubin 9.6
Indirect Bilirubin 3.2 PT 48.8
Alkaline Phosphate 86

Aspartate Transaminase 78
Alanine Transaminase 88
Aptt 73.7
Total protein serum 5.3
Albumin serum 3.1
INR 4.3
Globulin serum 2.4
A/G ratio 1.3:1
 ABG DAY-9
PH 7.344
Serum DAY-9
Electrolytes
PO2 46.8
PCO2 40.6
HCO3 22.0 Na 148

Lactate 2.08 K 4.6

IMPRESSION METABOLIC
Cl 101
ACIDOSIS WITH
LACTIC ACIDOSIS
 CBP Day0 Day2 Day3 Day4 Day5 Day 6 Day 7 Day 8 Day 9
HB 7.1 7.1 6.6 8.21 10.0 9.3 9.3 9.3 9.3
CBP CPOMPARISION OF ALL DAYS ( 1 PRBC
transfusion
done)
(1PRBC
transfusion
done)
(1 PRBC
transfusion
done)

WBC 27,800 27,300 12,800 12,100 12,800 12,600 12,000 11,000 11,000
DC N96,L1,E0,M N94,L2,E0,M N96,L1,E1,M5 N92,L1,E1,M N96, L1, E0, N92, L1, E1, N96, L1, E0 N92, L1, N92, L1,
5,B0 5,B0 ,Bo 5, B0 M5 B0 M5, Bo M5, B0 E1, M5, E1, M5,
Bo Bo

PLATELETS 2,30,00 2,10,000 2,30,000 1,90,000 2,30,000 2,10,000 2,00,000 1,50,000 1,50,00
0

MCV 75.5 75.5 75.9 76.9 75.9 76.9 81.9 78.9 78.5
MCH 23.9 23.9 24.4 25.1 24.4 25.1 32.2 32.7 33.2
MCHC 31.7 31.6 32.2 32.7 32.2 32.7 32.2 32.7 33.2
ESR 16 18 16 24 30 35 30 35 26
IMPRESSIO MICROCYTIC MICROCYTIC MICROCYTIC MICROCYTIC MICROCYTIC MICROCYTIC MICROCYTIC MICROC MICROC
N HYPOCHROM HYPOCHRO HYPOCHROMI HYPOCHRO HYPOCHROMI HYPOCHRO HYPOCHRO YTIC YTIC
IC ANEMIA MIC ANEMIA C ANEMIA MIC ANEMIA C ANEMIA MIC ANEMIA MIC HYPOCH HYPOC
ROMIC HROMI
C
 LFT Day 0 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9

Total 5.4 4.2 5.0 7.3 8.4 11.4 11.6 12.0 12.8
Bilirubin

Direct 3.4 3.4 3.9 5.6 6.7 8.7 8.8 8.7 9.6
Bilirubin

Indirect 2.0 0.8 1.1 1.7 1.3 2.7 2.8 3.3 3.2
Bilirubin

Alkaline 146 120 99 98 99 98 91 82 86

Phosphate

Aspartate 278 278 570 460 220 124 122 84 78

Transaminas
e

Alanine 229 450 422 371 222 155 150 108 88

Transaminas
e

Total protein 6.8 5.2 6.1 6.0 6.1 5.9 5.4 5.4 5.3
serum

Albumin 4.3 3.2 3.8 3.6 3.8 3.4 3.4 3.0 2.9
serum

Globulin 2.6 2 2.3 2.4 2.3 2.5 2.5 2.4 2.4

serum

A/G ratio 1.6:1 1.6:1 1.6:1 1.5:1 1.6:1 1.3:1 1.3:1 1.2:1 1.3:1
 Day0 Day2 Day3 Day4 Day5 Day6 Day7 Day8 Day9
PT INR APTT COMPARISIONOF ALL
DAYS
PT More 53.8 36.2 63.2 47.4 35.0 47.4 43.9 48.8
than 2 4 FFPS 2 FFPS 4 FFPS 2 FFPS
transf TRANSF transfu TRANSF
minutes USION USION
usion DONE sion DONE
done done
APTT 42.3 39.1 11.5 54.4 50.1 54.4 73.9 73.7

INR 4.6 3.2 5.4 4.12 3.0 4.12 3.8 4.3

 RFT Day 0 Day 2 Day3 Day4 Day5 Day6 Day 7 Day8 Day9

Urea 118 129 124 119 133 146 190 184 189

Creatin 3.7 3.7 3.5 3.7 3.1 2.9 2.2 2.0 1.8
ine
 Serum Day 0 Day 2 Day3 Day4 Day 5 Day6 Day7 Day8 Day9
Electrolytes

Sodium 134 134 132 137 138 137 144 146 148

Potassium 5.8 5.7 5.6 5.3 5.5 5.3 4.8 4.9 4.6

Chloride 104 103 104 104 105 104 109 111 108
• Patient is still on mechanical ventilator and suddenly
got desaturated, Bp not recordable with 3
inotropes ,carotids not felt
• Immediately high quality CPR was
initiated ,inj.adrenaline and inj.atropine 1cc was given
for every 5 min.
• Inspite of all the resuscitative efforts ,patient could not
be revived back and declared death with ECG showing
flat line at 1:37 A.M on 21/03/24.
Final Diagnosis

• SEPTIC SHOCK WITH MULTIORGAN

DYSFUNCTION SECONDARY TO INTRA
ABDOMINAL PATHOLOGY-?PERITONITIS
• K/C/O DCMP WITH SEVERE LV SYSTOLIC
DYSFUNCTION ( EF-25%), TYPE -2 DIABETES
MELLITUS