25 Year old Female with AKI , SEPSIS, MODS
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Thank you Dr Kulkarni Sir
2Nov 2022
25 YEAR OLD FEMALE Resident of Nalgonda
Chief Complaints:
Generalized edema on and off since 2months
Shortness of breath since 1week
Fever since 10 days
History of Presenting Illness:
Patient G2P1L1 was apparently asymmtomatic 2months back then she developed generalized edema for which she went to local RMP where she was diagnosed as Gestational Hypertension and started on medication. 1week later she developed seizures 2 episodes - Tongue bite and loss of consciousness present. She went to Yashoda hospital and MRI was done which showed PRES (Posterior Reversible Encephalopathy Syndrome) 2D Echo showed global hypokinesia. LV Dysfunction with 45%Ejection fraction
On 10/10/2022 (30 weeks of gestation) Emergency LSCS was done in view of fetal distress (cord around the neck) 960 gm female child.. In ot she had one episode of seizure for which she was intubated, antihypertensive, antiepileptics, laxics, blood transfusion done. One week later she was discharged as LAMA. She went to hospital in Nalgonda on 16/10/2022 when she had pedal edema where they found out deranged LFT and RFT, Dialysis was advised, her haemoglobin was 7gm/dl so blood transfusion was given. She went to another hospital with complaint of pedal edema, oliguria, facial puffiness - 3sessions of hemodialysis done and 2 blood transfusion.
Later she developed Shortness of breath grade 2 insidious in onset aggravated on lying down. Fever high grade not associated with chills and rigors. Burning micturation. Hemoptysis.
Complaint of headache during pregnancy
Past History:
No History of Diabetes, Thyroid, Tb , epilepsy,
No previous operation
Blood transfusion 3 sessions
Previous Pregnancy - Conceived spontaneous. All the trimester uneventful. Normal full term vaginal delivery. Baby Girl (current age 4 years).
Family History:
Elder sister died 3years ago due to seizures
Personal History:
Diet mixed
Appetite Normal
Bowel movement normal
Bladder Burning micturation
No addictions and allergies.
General examination:
Patient is conscious coherent and cooperative, well oriented to time place and person.
Moderately built and nourished.
Pallor present
Bilateral pedal edema
No Icterus, Clubbing, cyanosis, lymhadenopathy
Vitals:
Temperature Afebrile
BP 120/80 mmHg
Pulse rate 88bpm
Respiratory rate 18cpm
Systemic examination:
Respiratory system
Shape of chest elliptical, trachea central
Bilateral equal movements present
No scars, sinuses
Normal vesicular breath sounds
Cardiovascular system
JVP elevated
Apex beat left 5th intercoastal space
in mid clavicular line
S1, S2 heard, no murmurs.
Per Abdomen
Shape scaphoid, umbilicus everted
C Section scar present in lower abdomen
Soft no organomegaly
Tender in left iliac fossa
Bowel sounds heard
Central nervous system
Higher mental functions intact
Well oriented to time place and person.
No Focal Neurological Deficit
Investigations:
9th Nov
S:
SOB grade 4
Orthopnea
Vomiting 1 episode
Hemoptysis
Nausea subsided
O:
Patient is C/C/C
BP- 150/100 mmHg
PR- 100bpm
Temp- 99..7F
Sp02- 94% on ra
RR- 28cpm
CVS- S1,S2 + S3gallop loud P2
JVP raised
RS- BAE +
P/A- soft, non tender
CNS- NFND
A:
Renal AKI secondary to gram negative sepsis
MODS with DIC ( infective)
P:
INJ CLINDAMYCIN 600mg IV/BD
INJ. LASIX 80mg—X—40mg IV BD
INJ. ZOFER IV TID
T. NICARDIA RETARD 20mg PO BD
T. MET XL 50mg PO BD
T.LEVIPIL 500mg PO BD
INJ TRANEXA 50mg IV BD
INJ ERYTHROPOIETIN 4000 U SC OD
TAB TELMA 40mg PO OD
TAB MONTEC LC PO OD
INJ MEROPENAM 500mg IV OD
CPAP- NIV
Vitals monitoring 2hrly
Temperature charting 2hrly
Tests confirm Klebsiella
10 Nov
11 Nov
12 Nov
13 Nov
14 Nov
15 Nov
Patient attenders took her to home in misconception of black magic Taboo, where she was apparently same for 6-7 days. Then she developed worsening shortness of breath with decreased urine output.she was admitted at nearest corporate center.
At admission patient had breathlessness at rest with Generalised body swelling and decreased urine output. Evaluation was done.
30 Nov
Patient still on mechanical ventilator
HRCT done showing pulmonary edema
1December
Patient did not maintain even with 100 FiO2
Patient went into hypotension - Dual inotropes given
Attenders explained about poor prognosis
They took her home as LAMA
She expired at 11pm
Cause of death ARDS
Diagnosis:
Gram negative Sepsis
AKI secondary to MODS DIC
Autoimmune condition?
HUS TTP?
PRES (Posterior Reversible Encephalopathy Syndrome)
HELLP Syndrome ( Hemolysis Elevated Liver enzymes Low Platelets)
Heart failure secondary to Severe Anaemia.
Discussion
I have taken few details from the previous case sheet
Thank you Dr Kulkarni Sir
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