79 yr old female with Acute exacerbation of COPD with type 2 respiratory failure with cor pulmonale with post tuberculosis sequelae with left bronchiectasis with refractory hypotension secondary to septic shock with ventilator associated pneumonia with multi organ dysfunction syndrome on mechanical ventilation day 18 and tracheostomy tube day 8

79 yr old female came with complaints of shortness of breath, cough since 10 days

HOPI: Patient was apparently asymptomatic 10 days ago then she developed loss of appetite and sob which was insidious in onset (MMRC GRADE 2 TO 3), increased in supine position, not associated with wheeze, sweating and palpitations. Orthopnea PND -negative
C/o cough with expectoration since 10 days which is insidious in onset, progressive, mucopurulent, yellow in colour,non blood stained and non foul smelling
No c/o fever, chest pain, pedal edema, burning micturition, PND, wheeze.

PAST HISTORY: 
   H/O COPD SINCE 5 YEARS (ON NEB SOS)
   H/O PULMONARY TUBERCULOSIS 40 YEARS BACK (TOOK ATT FOR 6 MONTHS)
   K/C/O DIABETES MELLITUS SINCE 2 YEARS (ON REGULAR HYPOGLYCEMIC DRUGS)
   H/O BIOMASS EXPOSURE FOR 40 YEARS
   NOT A K/C/O HYPERTENSION, ISCHEMIC HEART DISEASE

FAMILY HISTORY: NO SIGNIFICANT FAMILY HISTORY

PERSONAL HISTORY: 
OCCUPATION: HOUSE WIFE
DIET : MIXED
APPETITE: LOSS OF APPETITE SINCE 10 DAYS
SLEEP : ADEQUATE
BOWEL AND BLADDER HABITS: REGULAR
NO ADDICTIONS
BIO MASS EXPOSURE FOR 40 TO 50 YEARS

GENERAL EXAMINATION:
PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE 

VITALS

TEMP-98.4 DEGREE F. PR-109 BPM, BP-110/70 MMHG, SPO2-99% @50 % FIO2, GRBS -140 MG/DL

NO PALLOR, ICTERUS, CYANOSIS CLUBBING, LYMPHADENOPATHY

SYSTEMIC EXAMINATION: CVS-S1 S2+

P/A-SOFT, NON TENDER, NO ORGANOMEGALY, BS + 
RS-BAE+, VBS DECREASED IN AL AREAS OF LEFT SIDE

BBS@RT SSA, INFRA SAY

CREPTS+@RT SSA INFRA SA, AA, IAA

TRACHEOSTOMY TUBE PLACED ON 15/2/2022

CENTRAL LINE PLACED ON 21/2/2022

 SPUTUM CENAAT-NEGATIVE

SPUTUM CULTURE SENSITIVITY (12/2/22)

-ACINETOBACTER SPECIES >10,000 CFU/ML ISOLATED WHICH IS SENSITIVE TO COTRIMOXAZOLE, COLISTIN

DEATH SUMMARY NOTES :

A 78 YEAR OLD FEMALE INTUBATED OUTSIDE THE HOSPITAL I/v/O ACUTE EXACERBATION OF COPD WITH TYPE 2 RESPIRATORY FAILURE WITH SEVERE PAH WITH COR PULMONALE ON 7/2/2022 AT AROUND 5:00 PM PATIENT LEFT AROUND MEDICAL ADVISE ON 7/2/2022 AT 5:30 PM AND PRESENTED TO KIMS CASUALITY ON THE SAME DAY AT AROUND 8:00 PM AND ADMITTED TO PULMONARY MEDICINE WITH IP NO-202205075 PATIENT WAS CONNECTED TO SIMV-VC AND VITALS WERE STABLE ROUTINE INVESTIGATIONS, ABG, CULTURE AND SENSITIVITY WERE SENT PATIENT WAS CONTINUED WITH PIPTAZ AND STEROIDS

C/S REPORTS SHOWED ACINETOBACTER WHICH WAS SENSITIVE ONLY TO COLISTIN AND   BACTRINE DS

PATIENT WAS GIVEN WITH WEANING TRIALS WHICH WERE NOT SUCCESSFUL SO WE CONTINUED MECHANICAL VENTILATION FOR 7 DAYS ON 15/2/2022 (DAY 9 OF MECHANICAL VENTILATION) AS PATIENT WAS VENTILATOR DEPENDENT AND TO PREVENT VAP ,TRACHEOSTOMY WAS PERFORMED UNDER LOCAL ANAESTHESIA BY ENT DEPARTMENT

REPEAT ET SECRETION C/S WHICH SHOWED ACINETOBACTER ISOLATES AGAIN INITIALLY
PATIENT WAS UNDER COLISTIN, BUT HER REPEAT WBC SHOWED INCREASING PATTERN SO BACTERIN DS WAS ALSO ADDED
 ON 21/2/2022, 8:00 AM, DAY 17 OF MECHANICAL VENTILATION HER BP WAS 90/60 MMHG SO NORAD WAS STARTED ACCORDING TO 0.05-0.1 MG/KG/MIN @ 2ML/HR AND IT WAS GRADUALLY INCREASED LATER ON DOBUTAMINE WAS STARTED 2 MCG/KG/MIN ON 22/2/2022,THERE WAS FALL IN BP (70 MMHG-SBP) SO VASOPRESSIN WAS STARTED 0.01 IU/MIN@ 1.5 ML/HR..

AS HER BP WAS NOT MAINTAINING, IONOTROPES WERE UNDER INCREASING PATTERN. ON 23/2/2022 10:05 AM HER BP-NR, SPO2-NR, CPR WAS INITIATED, 7 CYCLES OF CPR WERE DONE COULD NOT BE REVIVED DESPITE OF ALL THE EFFORTS. LATER ECG WAS TAKEN WHICH SHOWED NO ELECTRICAL ACTIVITY AT 10: 35 AM AND DECLARED DEATH.


IMMEDIATE CAUSE OF DEATH - REFRACTORY HYPOTENSION SECONDARY TO SEPTIC SHOCK WITH VAP WITH MODS WITH TYPE 2 RESPIRATORY FAILURE

ANTECEDENT CAUSE - ACUTE EXACERBATION OF COPD WITH TYPE 2 RESPIRATORY FAILURE WITH COR PULMONALE WITH POST TB SEQUELAE LEFT BRONCHIECTASIS WITH
REFRACTORY HYPOTENSION SECONDARY TO SEPTIC SHOCK WITH VAP WITH MODS


ABG 08-02-2022 12:19:AM

PH    7.32
PCO2.   48.9
PO2       172
HCO3     25.0
St.HCO3    24
BEB.    -0.5
BEecf    -0.2
TCO2     53.5
02 Sat     98.2
02 Count.   12.8

ABG 09-02-2022 01:27:PM

PH    7.46
PCO2   58.0
PO2   254
HCO3    41.5
St.HCO3  39.7
BEB    15.7
BEecf   41.5
TCO2    85.9
02 Sat   99.1
02 Count  13.9

ABG 11-02-2022 10:11:AM

PH    7.36
PH   7.35
PCO2   64.8
PC02.  68.7
PO2   46.8
PO2   170
HCO3  36.4
HCO3   37.7
St.HCO3  33.7
St.HCO3   33.2
BEB  10.4
BEB   9.4
BEecf  11.9
BEecf  10.8
TCO2.  78.5
TCO2.   74.8
02 Sat.   76.7
02 Sat.   98.1
02 Count. 16.1
02 Count  11.8

ABG 12-02-2022 10:19:AM

PH    7.36
PCO2   63.2
PO2   92.5
HCO3  35.0
St.HCO3  31.8
BEB  8.1
BEecf  9.4
TCO2   71.7
02 Sat  95.9
02 Count  15.9

ABG

13-02-2022 09:43:AM

PH   7.34
PCO2  72.9
PO2  196
HCO3  38.3
St.HCO3  34.3
BEB  10.5
BEedf  12.2
TC02  79.6
02 Sat  98.5
02 Count  15.5

ABG

14-02-2022 10:46:PM

PH  7.48
PCO2  53.0
PO2   144
HCO3   39.5
St.HCO3  38.7
BEB   14.9
BEecf  14.9
TCO2   87.1
02 Sat  98.8
02 Count  6.6

ABG 15-02-2022 06:55:AM

PH   7.48
PCO2    86.1
PO2    141
St.HCO3  61.3
BEecf  36.0
TCO2   130.4
02 Sat   98.2
02 Count   13.7
HCO3   63.4
BEB   33.8

ABG 16-02-2022 03:30:PM

PH  7.53
PH  7.38
PCO2   52.8
PCO2   71.1
PO2 226
PO2   104
HCO3   41.4
HCO3   44.0
St.HCO3   43.0
St.HCO3   38.8
BEB    18.9
BEB    15.0
BEecf 15.5
BEecf 19.2
TCO2   93.4
TCO2   90.0
02 Sat   96.4
02 Sat   99.0
02 Count   10.1
02 Count   9.4

ABG 17-02-2022 11:14:AM

PH  7.50
PH  7.53
PCO2  56.8
PCO2 67.1
PO2  199
PO2  239
HCO3  47.4
HCO3  52.2
St.HCO3  49.7
St.HCO3  45.6
BEB  21.0
BEB  24.4
BEecf  26.2
BEecf  22.2
TCO2  95.0
TCO2  104.9
02 Sat  98.6
02 Sat  99.0
02 Count  15.8
02 Count  15.9

ABG 18-02-2022 05:18:AM

PH   7.52
PCO2  60.0
PO2   224
HCO3 49.2
St.HCO3  48.0
BEB  23.4
BEecf 23.7
TCO2  105.4
02 Sat  99.1
02 Count  9.3

ABG 19-02-2022 10:43:AM

PH  7.11
PH  7.19
PH  7.40
PCO2  64.8
PCO2  78.4
PCO2  126
PO2  154
PO2  230
PO2  79.3
HCO3  40.0
HCO3   29.3
HCO3   39.1
St.HCO3  37.8
St.HCO3 30.1
St.HCO3  25.4
BEB   1.2
BEB   6.2
BEB   14.0
BEecf   14.6
BEecf   9.8
BEecf   1.9
TCO2  66.1
TC02   86.3
TC02   86.2
02 Sat   98.0
02 Sat   97.6
02 Sat   90.3
02 Count   9.0
02 Count   15.4
02 Count   10.3

ABG 20-02-2022 09:59:AM

PH   7.41
PH  6.87
PCO2  136
PCO2  60.8
PO2  206
PO2  66.9
HCO3  24.0
HCO3  38.6
St.HCO3 18.5
St.HCO3  36.4
BEB   -7.0
BEB  12.6
BEecf  13.3
BEecf   -8.5
TCO2  61.9
TCO2  81.4
02 Sat 98.6
02 Sat  79.6
02 Count  3.3
02 Count 12.3

ABG 21-02-2022 01:24:PM

PH   7.14
PH  7.06
PCO2 109
PCO2  71.1
PO2  154
PO2  48.0
HCO3 29.3
HCO3 23.6
St.HCO3  20.7
St.HCO3 22.8
BEB   -1.7
BEB   -4.4
BEecf  -4.2
BEecf  -0.4
TCO2  68.5
TCO2 54.6
02 Sat  98.3
02 Sat  77.7
02 Count 8.0
02 Count 7.9


Treatment Given (Enter only Generic Name)

1.INJ COLISTIN 2.5 GMS IV BD FOR 11 DAYS

2 INJ PIPTAZ 4.5 GM IV FOR 7 DAYS

3.INJ BACTERIM DS FOR 7 DAYS

4.INJ PAN 40 MG IV OD

5.INJ HYDROCORT 50 MG IV BD

6.TAB BACTRUM DS RT (1X1)

7.NEB WITH IPRAVENT 4 TH HOURLY, BUDECORT 8 TH HOURLY, MUCOMIST 2ND HOURLY

8.IVF-1 NS @ 75 ML/HR, 1 RL @ 75 ML/HR

9.TAB METFORMIN 500 MG OD RT

10.TAB SILDENAFIL 25 MG RT TID

11.TAB PCM 650 MG TID RT

12. TAB DYTOR 10 MG OD

13,TAB UDILIV 300 MG RT TID

14.RYLES FEEDING 2ND HOURLY

15.CHEST PHYSIOTHERAPY, POSITION CHANGE, ET/ORAL SUCTIONING 2ND HOURLY

16. HEAD END ELEVATION 

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