Summary: The first case report in this project is documented below for thematic analysis (as in our previous y24Narketpally50n project cases linked earlier and below) and the case was also recently presented in the mortality meeting last week. More about the project by the PI here:https://adimolamakash.
As with many of our projects we are only able to access the case data after the current EMR processes the discharge summary, in this case the death summary.
Previous medicine department project case based reasoning and thematic analysis using Meta AI outcomes:
Hypokalemia project case report 1:
Age/Gender : 70 Years/Male
Address :
Discharge Type: Expired
Admission Date: 25/06/2024 01:47 PM Death Date: 26/06/2024 02:30 PM
Diagnosis
TYPE 2 RESPIRATORY FAILURE ON MECHANICAL VENTILATION
REFRACTORY HYPOTENSION
REFRACTORY HYPOKALEMIA
SEPTIC SHOCK WITH MULTI ORGAN DYSFUNCTION SYNDROME SECONDARY TO LEFT
LOWER LIMB CELLULITIS
Address :
Discharge Type: Expired
Admission Date: 25/06/2024 01:47 PM Death Date: 26/06/2024 02:30 PM
Diagnosis
TYPE 2 RESPIRATORY FAILURE ON MECHANICAL VENTILATION
REFRACTORY HYPOTENSION
REFRACTORY HYPOKALEMIA
SEPTIC SHOCK WITH MULTI ORGAN DYSFUNCTION SYNDROME SECONDARY TO LEFT
LOWER LIMB CELLULITIS
Case History and Clinical Findings
C/O SWELLING IN LEFT LOWER LIMB SINCE 2 DAYS
PATIENT WAS APPARENTLY ASYMPTOMATIC 2 DAYS BACK THEN HE DEVELOPED
SWELLING IN LEFT LOWER LIMB WHICH IS INSIDIOUS IN ONSET,GRADUALLY PROGESSIVE
TO PRESENT SIZE
H/O TRAUMA 3 DAYS BACK
H/O FEVER SINCE 3 DAYS
NO H/O BURNING MICTURATION , CONSTIPATION
WEAKNESS OF LIMBS ALL 4 LIMBS SINCE MORNING
K/C/O CKD ( ON CONSERVATIVE MANAGEMENT )
NORMAL APETITE,MIXED DIET
REGULAR BOWEL AND BLADDER MOVEMENTS
H/O ALCOHOL CONSUMPTION SINCE 30 YEARS AND STOPPED YEAR BACK
H/O SMOKING SINCE 30 YEARS
ON GENERAL EXAMINATION :
NO PALLOR,ICTERUS,CYANOSIS,
VITALS: TEMP : 99.5 F
PR : 110BPM
RR : 16CPM
BP: 80/60MMHG
SPO2 99%
GRBS 113MG/DL
SYSTEMIC EXAMINATION :
CVS: S1 S2 HEARD ,NO THRILLS, NO MURMURS
RS : NVBS HEARD , NO WHEEZE
PA: NO TENDERNESS , NO PALPABLE MASS , NO ORGANOMEGALY
CNS :CONSCIOUS, NORMAL SPEECH , NFND
SENSORY SYSTEM INTACT
MOTOR SYSTEM :
TONE : HYPOTONIA
POWER : U/L : 2/5
L/L : 2/5
REFLEXES : AREFLEXIA IN ALL 4LIMBS
PUPILS : B/L SLUGGISH REACTIVE
THIS IS CASE OF 70 YEAR 0LD MALE FARMER BY OCCUPATION , CHRONIC ALCHOLIC AND
SMOKER K/C/O CHRONIC KIDNEY DISEASE PRESENTED TO CASUALITY WITH Complaints of WEAKNESS OF BOTH UPPER AND LOWER LIMBS , BREATHLESSNESS AND DECREASED
URINE OUTPUT. PATIENT HAD HISTORY OF THORN PRICK 4 DAYS DAY TO LATERAL
ASPECT OF LEFT LEG ABOVE ANKLE FOLLOWED BY WHICH PATIENT HAD HIGH Grade
FEVER WITH CHILLS AND PAIN AND SWELLING OF LEFT LEG.
ON ADMISSION VITALS: TEMP :
99.5 F,PR : 110BPM,RR : 16CPM,BP: 80/60MMHG,SPO2 99%,GRBS 113MG/DL .
99.5 F,PR : 110BPM,RR : 16CPM,BP: 80/60MMHG,SPO2 99%,GRBS 113MG/DL .
CASE WAS
ADMITTED UNDER DEPT OF GENERAL SURGERY .
ADMITTED UNDER DEPT OF GENERAL SURGERY .
ABG WAS SENT WHICH SHOWED
SEVERE ACIDOSIS. ABG :PH :6.9,Pco2 : 72.3,PO2 : 59.0,HCO3 : 13.5 ;
SEVERE ACIDOSIS. ABG :PH :6.9,Pco2 : 72.3,PO2 : 59.0,HCO3 : 13.5 ;
O/E AREFLEXIA WAS
NOTED ON FOUR LIMBS. CASE WAS TAKEN OVER BY DEPT GENERAL MEDICINE I/V/O
HEMODYNAMIC INSTABILITY. IMMEDIATE FLUID RESUSITATION WAS DONE WITH 0.95% NS
1500ML IN FIRST 2 HOURS , 100MEQ NAHCO3 CORRECTION WAS GIVEN.INVESTIGATION
WERE SENT AND POTASSIUM SUPPLEMENTATION WAS STARTED WITH 40MEQ IN 500ML
O.9% NS .
NOTED ON FOUR LIMBS. CASE WAS TAKEN OVER BY DEPT GENERAL MEDICINE I/V/O
HEMODYNAMIC INSTABILITY. IMMEDIATE FLUID RESUSITATION WAS DONE WITH 0.95% NS
1500ML IN FIRST 2 HOURS , 100MEQ NAHCO3 CORRECTION WAS GIVEN.INVESTIGATION
WERE SENT AND POTASSIUM SUPPLEMENTATION WAS STARTED WITH 40MEQ IN 500ML
O.9% NS .
CASE WAS SHIFTED TO ICU FOR FURTHER MANAGEMENT.HEMOGRAM SHOWED
LEUCOCYTOSIS AND BIOCHEMICAL TESTS SHOWED RAISED RENAL PARAMETERS .
PATIENT WAS STARTED ON EMPERICAL BROAD SPECTRUM ANTIBIOTICS AFTER SENDING
BLOOD AND URINE CULTURES. MGSO4 DRESSING OF LEFT LOWER LIMB WAS DONE .
SERUM POTASSIUM WAS FOUND TO BE 2 AND POTASSIUM SUPPLEMENTATION WAS
CONTINUED .BUT WEAKNESS OF PATIENT WAS FURTHER WORSENED WITH Progressing
RESPIRATORY DISTRESS. AS BP WAS NOT IMPROVING INSPITE OF ADEQUATE FLUIDS
,INOTROPIC SUPPORT WITH WAS STARTED. ABG WAS SENT WHICH SHOWED TYPE 2
RESPIRATORY FAILURE WITH PH 6.9 ,HCO3 13.5 ,PCO2 72.3;PO2 59 . PATIENT GRADUALLY
STARTED BECOMING DROWSY FURTHER AND THE NEED OF INTUBATION WAS
CONSIDERED AND ELECTIVE INTUBATION WAS DONE WITH ET TUBE NO 7 AND POSITION
WAS CONFIRMED WITH MIST IN ET TUBE AND 5 POINT AUSCULTATION AND CONNECTED
TO MECHANICAL VENTILATION . AT 11 30 AM PATIENT DEVELOPED SUDDEN CARDIAC
ARREST WITH NON RECORDABLE BP AND PR , 2CYCLES OF CPR WAS DONR AFTER WHICH
RETURN OF SPONTAN
EOUS CIRCULATION WAS ACHIEVED AT Around 1 45 PM BP AND PR WAS NON
RECORDABLE AND CPR WAS INITIATED ACCORDING TO LATEST ACLS GUIDELINES AND
CONTINUED FOR 30 MINUTES . INSPITE Of Above Resuscitative EFFORTS PATIENT
Could Not BE REVIVED AND DECLARED DEAD AT 2:30PM ON 26/6/24 WITH ECG SHOWING
ISOELECTRIC LINE.
IMMEDIATE CAUSE OF DEATH : TYPE 2 RESPIRATORY FAILURE , REFRACTORY
HYPOTENSION ,REFRACTORY HYPOKALEMIA
ANTECEDENT CAUSE OF DEATH : SEPTIC SHOCK WITH MULTI ORGAN DYSFUNCTION
SECONDARY TO LEFT LOWELIMB CELLULITIS
Investigation
SEROLOGY : NEGATIVE
CBP : HB: 13.9
TLC : 22,000
PLT COUNT: 1.42
BLOOD GROUP : A NEGATIVE
BT : 2 MIN 00 SEC
CT : 4 MIN 30 SEC
CUE :
COLOUR : PALE YELLOW
ALBUMIN : 3+
SUGAR, BILE SALTS,BILE PIGMENTS : NIL
PUS CELLS : 4 TO 5
EPITHELIAL CELLS : 2 TO 4
PROTHROMBIN TIME : 17 SEC
INR : 1.25
APTT : 35 SEC
RBS : 81 MG/DL
LFT :
TB : 1.15
DB : O.30
SGOT : 22
SGPT : 20
ALP : 177
TP : 5.3
ALB: 2.8
A/G :1.18
RFT
UREA : 128 MG/DL
CREAT : 3.7 MG /DL
URIC ACID : 8.8
SODIUM : 132
POTASSIUM :2.O
CHLORIDE : 102
ABG :
PH :6.9
Pco2 : 72.3
PO2 : 59.0
HCO3 : 13.5
BLOOD LACTATE : 15 MG/DL
SR MAGNESIUM : 1.9 MG/DL
USG : GRADE 1 RPD CHANGES IN RIGHT KIDNEY
GRADE 2 RPD CHANGES IN LEFT KIDNEY
LEUCOCYTOSIS AND BIOCHEMICAL TESTS SHOWED RAISED RENAL PARAMETERS .
PATIENT WAS STARTED ON EMPERICAL BROAD SPECTRUM ANTIBIOTICS AFTER SENDING
BLOOD AND URINE CULTURES. MGSO4 DRESSING OF LEFT LOWER LIMB WAS DONE .
SERUM POTASSIUM WAS FOUND TO BE 2 AND POTASSIUM SUPPLEMENTATION WAS
CONTINUED .BUT WEAKNESS OF PATIENT WAS FURTHER WORSENED WITH Progressing
RESPIRATORY DISTRESS. AS BP WAS NOT IMPROVING INSPITE OF ADEQUATE FLUIDS
,INOTROPIC SUPPORT WITH WAS STARTED. ABG WAS SENT WHICH SHOWED TYPE 2
RESPIRATORY FAILURE WITH PH 6.9 ,HCO3 13.5 ,PCO2 72.3;PO2 59 . PATIENT GRADUALLY
STARTED BECOMING DROWSY FURTHER AND THE NEED OF INTUBATION WAS
CONSIDERED AND ELECTIVE INTUBATION WAS DONE WITH ET TUBE NO 7 AND POSITION
WAS CONFIRMED WITH MIST IN ET TUBE AND 5 POINT AUSCULTATION AND CONNECTED
TO MECHANICAL VENTILATION . AT 11 30 AM PATIENT DEVELOPED SUDDEN CARDIAC
ARREST WITH NON RECORDABLE BP AND PR , 2CYCLES OF CPR WAS DONR AFTER WHICH
RETURN OF SPONTAN
EOUS CIRCULATION WAS ACHIEVED AT Around 1 45 PM BP AND PR WAS NON
RECORDABLE AND CPR WAS INITIATED ACCORDING TO LATEST ACLS GUIDELINES AND
CONTINUED FOR 30 MINUTES . INSPITE Of Above Resuscitative EFFORTS PATIENT
Could Not BE REVIVED AND DECLARED DEAD AT 2:30PM ON 26/6/24 WITH ECG SHOWING
ISOELECTRIC LINE.
IMMEDIATE CAUSE OF DEATH : TYPE 2 RESPIRATORY FAILURE , REFRACTORY
HYPOTENSION ,REFRACTORY HYPOKALEMIA
ANTECEDENT CAUSE OF DEATH : SEPTIC SHOCK WITH MULTI ORGAN DYSFUNCTION
SECONDARY TO LEFT LOWELIMB CELLULITIS
Investigation
SEROLOGY : NEGATIVE
CBP : HB: 13.9
TLC : 22,000
PLT COUNT: 1.42
BLOOD GROUP : A NEGATIVE
BT : 2 MIN 00 SEC
CT : 4 MIN 30 SEC
CUE :
COLOUR : PALE YELLOW
ALBUMIN : 3+
SUGAR, BILE SALTS,BILE PIGMENTS : NIL
PUS CELLS : 4 TO 5
EPITHELIAL CELLS : 2 TO 4
PROTHROMBIN TIME : 17 SEC
INR : 1.25
APTT : 35 SEC
RBS : 81 MG/DL
LFT :
TB : 1.15
DB : O.30
SGOT : 22
SGPT : 20
ALP : 177
TP : 5.3
ALB: 2.8
A/G :1.18
RFT
UREA : 128 MG/DL
CREAT : 3.7 MG /DL
URIC ACID : 8.8
SODIUM : 132
POTASSIUM :2.O
CHLORIDE : 102
ABG :
PH :6.9
Pco2 : 72.3
PO2 : 59.0
HCO3 : 13.5
BLOOD LACTATE : 15 MG/DL
SR MAGNESIUM : 1.9 MG/DL
USG : GRADE 1 RPD CHANGES IN RIGHT KIDNEY
GRADE 2 RPD CHANGES IN LEFT KIDNEY
Treatment Given(Enter only Generic Name)
1. RYLES FEED MILK 50ML 4TH HOURLY AND WATER 50ML 2ND HOURLY
2. INJ KCL 40 MEQ IN 50OML NS /IV /5HOURS
3. INJ OPTINEURON 1 AMP IN 100ML NS/IV/OD 2 PM
4. INJ MEROPENEM 500MG IV/BD
5.INJ PAN 40 MG IV/OD 8 AM
6. INJ MGSO4 1 AMP IN 100ML NS/IV /STAT
7. TAB PCM 650MG RT/SOS
8. MGSO4 DRESSING OF LEFT LOWER LIMB AND ELEVATION
9. POSITION CHANGE 2ND HOURLY
10.ORAL AND ET SUCTIONING 2ND HOURLY
11. VITALS MONITORING , I/O CHARTING HOURLY
12. INJ NORAD 2 AMP IN 46 ML NS @ 5ML/HR INCREASE OR DECREASE TO MAINTAIN MAP
>65MMHG
13. INJ PIPTAZ 4.5 GM /IV/STAT
14. INJ CLINDAMYCIN 600MG IV/TID
15. INJ SODIUM BICARBONATE 100MEQ IV/SLOWLY OVER 20 MINUTES
16. TAB SPIRONOLACTONE 50MG PO/BD
Death Date
Date:26/6/24
Ward:ICU
Unit:2
Faculty Signature
SIGNATURE OF PATIENT /ATTENDER :
SIGNATURE OF PG/INTERNEE:
Discussion dyadic:
[05/07, 16:38] : Hypokalemia theme points:
Hypokalemia in renal failure patient is challenging as renal failure can cause hyperkalemia and dose titration needs to be very meticulous
His type 2 respiratory failure was also due to hypokalemic paralysis?
[05/07, 16:41] : Need to know how much potassium ultimately went into the patient and what was the repeat potassium result
[05/07, 17:01] Pushed Communicator 1N22: His respiratory failure was due to hypokalemia only sir
[05/07, 17:01] Pushed Communicator 1N22: Almost 200 meq k was given in total
[05/07, 17:02] Pushed Communicator 1N22: Starting k was 2 meq and we repeated k every 6 hourly and it remained 2 till the last
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