central mortality meet for a child case.pptx

Mortality meet case study

1. Mortality Meet Presenter - Dr.Kumar Satyam PG IInd Year Dept.Of Medicine

2. PARTICULARS Name- Mr Nathi Ram Age - 57 years Sex - male Occupation- ex serviceman Address- Dehradun DOA - 30/8/19 DOE - 15/9/19 TREATING DOCTOR- Dr. Pankaj Dixit

3. Patient was a F/c/o ALCOHOL related CLD for 6 months. He was consuming alcohol on –off during his course of illness. He was brought to the OPD on 30 th aug 2019 with the chief complaints of 1) Abdominal distension , gradually progressive in nature x 15d 2) Decrease apetite x 10 d There was no h/o fever, vomiting, altered bowel , hematemesis malena , epistaxis no/h/o cough, breathlessness, headache no h/o joint pain.,night sweats.

4. PAST HISTORY- No H/O TB/HTN/T2DM . PERSONAL HISTORY - Mixed diet, bowel/bladder normal, sleep increased, non smoker, chronic alcoholic. FAMILY HISTORY – no family history of any similar illness

5. General physical examination Pallor – absent Icterus - Present Cyanosis-absent Clubbing -absent Lymphadenopathy - absent Pedal Oedema – Present JVP not raised NO rash over the body Thin built and looking malnourished PULSE-80/min, regular, normal in volume, character, no RR-RF delay,all peripheral pulses present. BP-110/70 mmhg TEMPERATURE- afebrile SPO2-95% ON ROOM AIR

6. SYSTEMIC EXAMINATION RESPIRATORY SYSTEM Trachea central, All lung fields resonant on percussion B/L air entry present. no added sounds present . CVS Apex beat is present in normal position. S1 S2 heard normally in all areas. S3 / S4 absent, No murmur , no pericardial rub ABDOMEN EXAMINATION Distended , non tender , no hepatosplenomegaly , diffusely dull note found, bowel sounds present CNS Conscious oriented All cranial nerve are intact No Motor and sensory deficit. Normal deep tendon Reflexes NO meningeal signs .

7. Reports 26/ 8/ 19 Usg w/a s/o CLD with Portal HTN with mod spleenomegaly with mod ascites. Hb- 11.0 Tlc – 4190 ( N 90%) Esr - 65 T. Bil - 16.8 S. Alb- 2.7 S.Urea - 24 S.Cret-1.1 INR – 2.59 HIV /HBsAg / Anti HCV - NR

8. TREATMENT – started with 1)Antibiotics ( cefperazone 2gm iv bd) 2)Diuretics ( Lasix 10 mg iv bd) 3) Colloid ( inj albumin 100ml iv od) x 5d 4)PPI ( inj pantop 40mg iv bd) 5) inj thiamine 100mg iv bd 6) Inj terlipressin 1mg iv tid 7) Inj vit K 1 amp iv od x 3 d 8) syp lactulose 30ml od hs 9) paracentesis dx as well as rx 10) Salt restriction and maintenance with DNS / 1 amp KCL Patient was shifted to ward and advised for CBC, LFT, RFT and ascitic fluid analysis.

9. Lab Values ( 31/8 – 1/9) Hemoglobin - 10.2gm/dl TLC- 4560 cells/ cumm Platelets-150000 PCV = 29.3 , ASCITIC FLUID ANALYSIS TLC /DLC - 250 ( 90% L) GLU- 105 PROTEIN-2.0 ALBUMIN -1.1 . T .BIL – 19.5mg/dl DIRECT- 16.3 mg/dl . SGOT-122 U/L SGPT-48 U/L ALP- 80 U/L GGT- 103 U/L ALBUMIN- 2.7 UREA/ CREAT – 91/ 2.9 Sr.Na-134mmol/l Sr.K - 3.6 mmol/l S.Protein - 8.1 g/dl

10. Working Dx (1/9) ALCOHOL RELATED DECOMPENSATED CLD WITH PORTAL HYPERTENSION WITH ASCITES WITH RENAL FAILURE , LIKELY S/O HEPATO RENAL SYNDROME TYPE 1 PLAN – Patient appear sick , was maintaining his vitals , So CST UNDER OBSERVATION in ward and monitor RFT.

11. HOSPITAL COURSE 2/9 – 5/9 GC – Sick Vitals Stable Afebrile Urine output – normal Rx - CST

12. 02/09 03/09 05/09 UREA 64 67 85 CRET 1.4 1.6 2.5 Na 130 137 132 K 3.5 3.6 3.7 T. BIL 19.0 DIRECT BILIRUBIN 15.8 SGOT 119 SGPT 53 ALBUMIN 2.3

13. HOSPITAL COURSE 6/9 – 8/9 GC – Sick Vitals Stable Afebrile Urine output – Decreased Abdomen distended with mild pain. ADV Dx( TLC/ DLC) and Rx Ascitic Tap , repeat LFT, CBC Rx- CST

14. 07/ 09 08/09 UREA CRET Na K Hb TLC/ DLC PCV T.BIL DIRECT SGOT SGPT ALBUMIN ASCITIC FLUID ANALYSIS TLC DLC 07/ 09 08/09 UREA 118 147 CRET 5.5 6.7 Na 129 130 K 4.1 4.0 Hb 10.0 TLC/ DLC 6250 ( 82% N) PCV 29 T.BIL 25.4 DIRECT 21.6 SGOT 131 SGPT 53 ALBUMIN 2.5 ASCITIC FLUID ANALYSIS TLC DLC 100 90% N

15. HOSPITAL COURSE 9/9 – 11/9 GC – Sick, Patient having excessive sleepiness, oriented Vitals Stable Afebrile Urine output – Decreased Abdomen distended. ADV Revised (9/9) Inj albumin 100 ml iv od x 5 d Tab Thiotress ( Glutathione) 500mg bd Syp sanlooz ( lactulose) 30 ml tds R/CST Shift to HDU Ascitic fluid dx tap c/m Nephrology reference c/m

16. INV 10/09 11/09 UREA 170 178 CRET 7.1 7.5 Na 129 134 K 4.3 3.5 ASCITIC FLUID ANALYSIS TLC DLC ALB PROTEIN GLUCOSE 800 70% L 1.0 2.1 92

17. Patient attendents could not arrange albumin and refused for shifting to HDU. Nephro ref advised for HD. Patient was eventually shifted to HDU by evening of 11/09. Patient was drowsy but maintaining vitals at time of arrival in HDU. He underwent a session of HD at around 5pm and returned back to HDU by 8 pm. HD session was uneventful. In night patient suddenly went into gasping state , GCS- E1 V1 M1 BP-100/60 mmHg SpO2- 75 % with O2 support. Urgent Anestheisist ref was done and it was decided to intubate the patient and shift to medical ICU and put him on mechanical ventilation.

18. HOSPITAL COURSE 12/9 GC – CRITICAL , unconscious He was on mechanical ventilation Vitals Unstable , patient needed vasopressor support to maintain BP Afebrile Urine output – Decreased Abdomen distended. ADV repeat LFT, CBC Rx- CST and supportive Patient attendents could not arrange for albumin.

19. 13/09 GC – CRITICAL , unconscious He was on mechanical ventilation Vitals Unstable , patient needed vasopressor support to maintain BP Afebrile Urine output – Decreased Abdomen distended. Not passing stool In evening BP got NR despite vasopressor support.

20. INV 12/09 13/09 14/09 UREA 119 128 133 CRET 6.1 8.3 9.2 Na 134 140 139 K 3.5 4.1 5.1 T.BIL 24.0 25.8 23.6 SGOT 172 2014 3677 SGPT 117 570 1080 ALBUMIN 2.6 2.8 2.6 INR 3.3 Hb 7.6 8.5 TLC/DLC 555O( 87%N) 7400 (84%N) PCV 21.1 24.5

21. 14/09 Condition remained same , patient developed lactic acidosis. Patient regained BP by morning but remained in shock despite vasopressor support. At 1.45 am of 15/09 patient underwent a cardiopulmonary arrest, vitals became NR, for which CPR was given but patient couldn’t be revived and declared dead at 2.20 AM.

22. Cause of death – HRS SHOCK

23. THANK YOU