A 60 /F with shortness of breath and renal calculi

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A 60yr old female who was a daily wage laborer but has been a homemaker for the past 10 yrs was wheeled into the casualty with the 

Chief complaints: 

• Shortness of breath (grade -IV) since yesterday

History of present illness: 

• 2 months prior to admission she had complained of decreased urine output, dribbling of urine associated with bilateral pedal edema and, loin pain, with no facial puffiness, or shortness of breath. She then went to a local RMP and received treatment and her urine output improved but pedal edema persisted. 
• 1 week prior to admission, she went to Miryalaguda and got ultrasonography done which showed an 11mm right mid ureteric calculi and was referred to our hospital where tamsulin, oflox, citrallca were prescribed and CT KUB and IVP were planned for her.
• Since yesterday patient started to experience shortness of breath even at rest ( grade-IV), with orthopnea and pedal edema but no PND 
• After IVP, the patient was asked to drink more water for a repeat procedure, however, during the procedure, the patient suddenly became breathless and was brought to casualty, improved with nebulizations, hydrocort, and avil 

Past history : 

-Not significant

Personal history : 

• Appetite - normal 
• Diet - mixed
• Bowel and bladder - Regular bowel movements, burning micturition
• Sleep- has disturbed sleep for the past 20 days after abruptly stopping his medications.
• Addictions - Smokes chutta 2/day since 30 yrs 

On examination : 

Pt is c/c/c

No signs of pallor, icterus, cyanosis, clubbing, lymphadenoapathy

 pedal edema +

Vitals:

Afebrile

PR: 80bpm

RR: 28cpm

BP: 110/70 mmHg

Systemic examination :

 CVS:S1,S2 heard

Resp:

Dyspnoea +nt

BAE+

No wheeze

Nvbs heard

P/A: obese,  tenderness present, bowel sounds heard

Cns: NFND

Provisional diagnosis :

1- post renal AkI - Egfr-31 

2- Right ureteric calculi -with mild hydroureteronephrosis

3- ? Retroperitoneal Abscess 

4- Sob under evaluation-

 SVT ? 

ECG at 12 pm

Next day ECG

IVP report

CT KUB REPORT

Investigations

  

Day 2 morning vitals - 

Temp - 100.6 

PR- 130/ min ,regular .

BP-90/60 mmHg 

RR-30/ min 

Spo2- 97 @ room air 

ECG - showing - narrow complex ,regular with absent p waves .

2D echo

Death summary

60yr old female dailywage labourer (since 10yrs -homemaker) had complaints of decreased urine output,dribbling of urine ass with bilateral pedal edema, loin pain since 2 months

No facial puffiness, no sob

For which they went to the local RMP and received treatment and urine output improved but pedal edema persisted, 1 week back usg done which showed 11mm right mid ureteric calculi narketpally. Here tamsulin, oflox, citrallca were prescribed and planned CTKUB and IVP. 

Pt gives history of SOB since yesterday, orthopnea present, no PND, pedal edema present

After IVP, pt asked to drink more water for repeat procedure, During the procedure, pt suddenly became breathless and brought to casualty, improved with Nebulizations,hydrocort,avil ..

Smokes chutta 2/day since 30 yrs ..Day 2 of admission she had high heart rate and tachypea, ecg shows sinus tachycardia .. she has given tab ivabridin 5 mg stat and monitored 2 nd hourly. On day 3 since afternoon patient had hypotension and review 2 D echo done shows mild LVH and started on inotroph NA double strength @ 4ml/hr and increased accordingly to maintain MAP of 55 mm of hg . Patient bp has not improved even on inotrophs and had sudden cardiac arrest at 7 pm .CPR initiated according to AHA guidelines. Despite of rescuitation and efforts patient couldnot be revived and declared death on 6/9/2021 at. 7:45  Pm

Immediate cause of death : refractory hypotension 

Sepsis with MI

Antecedent cause:

post renal AkI - Egfr-31 

 Right ureteric calculi -with mild hydroureteronephrosis

? Retroperitoneal Abscess 

Sob under evaluation

Denovo DM present