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1. CONTINUOUS QUALITY IMPROVEMENT DURATION OF STAY – 24hours PRESENT ATOR – Dr. Y. Ramani reddy 1st year Post G raduate Department of General Medicine

2. CHIEF COMPLAINTS A 50 year old female presented to ER with the chief complaints of Shortness of breath sin ce 3days Decreased urine output from 6hours

3. HISTORY OF PRESENT ILLNESS Patient was apparently normal 3days back after which present complaint started as Complaints of SOB, insidious progressive from grade 2 to grade 4 , no orthopnea , no PND Complaints of decreased urine output from 6hours not associated with pain abdomen and abdominal distension

4. No complaints of vomiting and loose stools No complaints of chest pain , cough , hemoptysis . No complaints of blurring of vision, involuntary movements and headache , reeling sensation

5. PAST HISTORY No History of similar complaints in the past. K/c/o diabetic and hypertensive No history of CVA , CAD , Pulmonary TB , Epilepsy and bronchial asthma No H/o blood transfusion
No H/o surgeries in the past K/c/o CKD not on hemodialysis

6. PERSONAL HISTORY Mixed diet Regular bowel and bladder habits Not a smoker , alcoholic FAMILY HISTORY - Nil significant

7. General condition on examination Patient is altered and disoriented Moderately built and nourished . pallor + No icterus No cyanosis No clubbing No lymphadenopathy edema +

8. Vitals at the time of presentation BP- 200/100 mmhg treated with i.v labetalol 20mg I.V PR- 107 /min RR- 42 /min SPO2- 77 % @RA . 87 %on fio2 90% peep 5cm H20 Temp-afebrile

9. Systemic Examination Inspection Shape of the chest is elliptical Shape of the spine is normal. Trachea appears to be in midline. Movements of the chest are bilaterally symmetrical during respiration in all regions. No visible pulsations or discharging sinuses or scars.

10. Palpation Trachea is in midline Apex beat palpable at half inch medial to the mid clavicular line in the left fifth intercostal space. Respiratory movements are bilaterally symmetrical in all the areas. No tenderness or rib crowding.

11. Percussion Resonant note heard in all areas Auscultation B ilateral air entry + Diffuse coarse crepts present

12. CVS S1,S2 heard No murmurs P/A S oft ,non tender No organomegaly Bowel sounds present CNS B/L Pupils- B/L NSRL Plantars – B/L flexors GCS – 10/15

13. Provisional diagnosis ACUTE ON CHRONIC KIDNEY DISEASE WITH SEVERE METABOLIC ACIDOSIS WITH K/C/O HYPERTENSION AND DIABETIC

14. Investigations at admission

15. Chest xray

16. USG ABDOMEN AND PELVIS Hepatomegaly with Grade 1 fatty liver Bilateral grade 2 renal parenchymal changes

17. Patient was intubated in view of low GCS and impending respiratory failure Post procedure vitals Temp: afebrile PR : 112bpm BP: 150/100mmhg Spo2 : 99%with fio2 100% RR: 19cpm vitals Temp : afebrile PR : 140bpm BP: 160/100 mmhg Spo2 : 87%@NIV with fio2 100% RR: 35cpm

18. Treatment @ Admission Vitals Temp : afebrile PR : 140bpm BP: 160/100 mmhg Spo2 : 87%@NIV with fio2 100% RR: 35cpm Inj CEFPERAZONE + SULBACTAM 1.5gm i.v BD Inj LASIX 40mg I.V BD if BP >130/80 Inj PANTOP 40mg i.v od T.SODOCEL 500mg R/T tid T.FEBUXOSTAT 40mg R/T od Inj H.ACTRAPID S/C

19. CBP 25 / 7 /24 26 / 7 /24 HB 6.8 7.2 WBC 21.3 19.9 DC N 88 , L 7 , E ,M 4, B0 N 91, L 3, E 1 ,M 5 ,B0 Platelets 2.44 lac 2.34lac ESR 107 80 MCV 91.9 91.0 MCH 31.7 31.7 MCHC 3 4.5 3 4.9 Impression Normocytic normochromic anemia with neutrophilic leucocytosis Normocytic normochromic anemia with neutrophilic leucocytosis

20. RFT 25 / 7 /24 26 / 7 /24 S.Urea 125 105 S.Creatinine 5.4 4.6

21. S.ELECTROLYTES Day1 25 / 7 /24 Day 2 6 / 7 /24 Sodium 137 140 Potassium 5.8 6.2 Chloride 10 6 107 Serum calcium 25/7/24 9.2 Phosphorus 25/7/24 6.43 Uric acid 25/7/24 9.0 Hba1c 25/7/24 8.4 TSH 25/7/24 8.99

22. LFT 25 / 7 /24 Total Bilirubin 0.5 Direct Bilirubin 0. 2 Indirect Bilirubin 0.3 Alkaline phosphatase 89 Aspartate Transaminase 40 Alanine Transaminase 43 Total Proteins serum 6.4 Albumin serum 3.9 Globulin serum 2. 5 A/G Ratio 1. 5 :1

23. Nephrology opinion Opinion was taken in view of elevated s.creatinine and s.urea and advised emergency hemodialysis was done with in 4hours of presentation

24. Cardiology opinion 2D ECHO No LV RWMA Good lv systolic function Mild MR/TR (RVSP : 48mmhg) Grade 2 LV diastolic dysfunction Ivc – normal and collapsing Advised T .ISOLAZINE (30/27.5) P/O BD

25. Other investigations Coagulation profile 25-07-24 PT 12.5 INR 1.1 aPTT 30.8 Viral markers HIV Non-reactive HBsAg Non reactive HCV Non-reactive

26. ABG 25-07-24 Post HD (25-07-24) 26-07-24 PH 6.943 7.310 7.068 PO2 Not calibrated Not calibrated Not calibrated PCO2 54.9 37.9 37.9 HCO3 10.1 18.7 9.6 Lactate 3.06 1.62 2.90 Impression Metabolic acidosis with lactic acidosis Metabolic acidosis Metabolic acidosis with lactic acidosis

27. Pre HD vitals Temp : afebrile BP : 130/80mmhg PR : 96bpm Spo2 : 93%fio2 100% RR : 29cpm Hemodialysis started with ijv catheter ( rt side) Duration of dialysis: 2hours 30minutes Heparin free and ultrafiltrate : 500ml Post HD vitals Temp : afebrile BP : 140/80mmhg PR : 94bpm Spo2 : 92%fio2 100% RR : 27cpm

28. 0n 26/7/24 at 2:10 Am patient suddenly desaturated and carotids not felt and pupils were non reactive immediately high quality CPR started according to ACLS guidelines and rhythm showed ventricular fibrillation immediately 150J shock was delivered and pt was resusciated Post CPR vitals BP : 150/80mmhg PR : 113bpm RR : 32cpm Spo2 : 89%on fio2 100% Grbs : 240mg/dl ABG shows metabolic acidosis: inj AUXISODA 100meq i.v given

29. 0n 26/7/24 at 8:40 Am patient suddenly desaturated and carotids not felt and pupils were non reactive immediately high quality CPR started according to ACLS guidelines and inj Atropine and Adrenaline given B.P is not recordable and carotids not felt. Despite of all above resuscitation measures patient cannot be revived and declared death on 26/7/24 at 9:08 Am with ecg showing flat line

30. FINAL DIAGNOSIS SEPSIS , ACUTE ON CHRONIC KIDNEY DISEASE WITH K/C/O T2DM , HYPERTENSION, DENOVO HYPOTHYROIDISM