65F, CKD ON MHD, AF WITH FVR, ANAEMIA OF CHRONIC DISEASE ,HFPEF(EF-( 59), K/C/O HYPERTENSION SINCE 5 YEARS.



PRESENTING COMPLAINTS :
SWELLING OF BOTH LOWER LIMBS SINCE 1 MONTH 
DIFFICULTY IN BREATHING SINCE 1 MONTH 
FEVER SINCE 1 WEEKs

HISTORY OF PRESENTING COMPLAINTS:
PATIENT WAS APPARENTLY ASYMPTOMATIC BEFORE 1 MONTH, GRADUALLY HAD SWELLING OF BOTH LOWER LIMB WHICH IS PROGRESSED FROM GRADE-3 TO GRADE-4.
DIFFICULTY IN BREATHING SINCE 1 MONTH, WHICH IS PROGRESSED FROM GRADE-3 TO GRADE-4
FEVER HIGH GRADE CONTINUOUS ASSOCIATED WITH CHILLS AND RIGORS.

PAST HISTORY:
 H/O SIMILAR COMPLAINTS PRESENT 4 DAYS BACK DURING DIALYSIS
K/C/O HYPERTENSION SINCE 5 YEARS
N/K/C/O. TB, ASTHMA, EPILEPSY, THYROID DISORDERS.

TREATMENT HISTORY:
ON TAB.NICARDIA 10 mg, BD, 
TAB. ARKAMINE 0.1 MG. PO. BD.

PERSONAL HISTORY: 
Diet - mixed 
Appetite - decreased
Bladder - decreased urine output
Bowel - regular
Sleep - inadequate
.No h/o Alcohol intake
No h/o.Smoking
No drug addictions 
FAMILY HISTORY:
No H/O HTN/DM/TB/ASTHMA/EPILEPSY/CAD/ THYROID DISORDERS in the family.

PROVISIONAL DIAGNOSIS 
CKD ON MHD
ANAEMIA OF CHRONIC DISEASE

GENERAL PHYSICAL EXAMINATION:
HEIGHT - 150 cms
WEIGHT - 60  kg
PALLOR - PRESENT
NO ICTERUS 
NO CYNOSIS 
NO CLUBBING 
NO LYMPHEDNOPATHY 

DAY 1 ON EXAMINATION: 12/07/2025 
TEMP - 98.2 f
PULSE - 92/min regular
BP - 130/90 mm of hg
RR - 20 / min
SPO2 - 98% on RA 
CVS -S1,S2 PRESENT, NO MURMURS 
RS - BAE -PRESENT , NVBS 
PA - SOFT , NON TENDER 
CNS - NFND 
GRBS - 101 mg/dl 
ECG ON 12/07/2025 12PM
INVESTIGATIONS ON 12/07/2025
TREATMENT ON 12/07/2025
T. Nicardia  
T. Arkamine 0.1 MG PO/BD  
T. Orofer XT PO/OD  
T. Nodosis 500 MG PO/BID  
T. Shelcal XT PO/OD  
T. Pregaba M PO/HS  
T. MVT PO/OD  

Fluid restriction <1.5 L/day  
Salt restriction <2 g/day  

DAY 2 ON EXAMINATION: 13/07/2025 
TEMP - 98.1 f
PULSE - 100/min regular
BP - 130/90 mm of hg
RR - 22 / min
SPO2 - 98% on RA 
CVS -S1,S2 PRESENT, NO MURMURS 
RS - BAE -PRESENT , NVBS 
PA - SOFT , NON TENDER 
CNS - NFND 
GRBS - 110 mg/dl

TREATMENT ON 13/07/202
T. Nicardia. PO. BD
T. Arkamine 0.1 MG PO/BD  
T. Orofer XT PO/OD  
T. Nodosis 500 MG PO/BID  
T. Shelcal XT PO/OD  
T. Pregaba M PO/HS  
T. MVT PO/OD 
 Fluid restriction <1.5 L/day  
Salt restriction <2 g/day  

DAY 3 ON EXAMINATION: 14/07/2025 
TEMP - 98.6 f
PULSE - 110/min regular
BP - 120/80 mm of hg
RR - 22 / min
SPO2 - 99% on RA 
CVS -S1,S2 PRESENT, NO MURMURS 
RS - BAE -PRESENT , B/L BASAL CREPTS PRESENT 
PA - SOFT , NON TENDER 
CNS - NFND 
GRBS - 100 mg/dl

ECG ON 14/07/2025 
INVESTIGATIONS ON 14/07/2025
TREATMENT ON 14/07/2025
T. Nicardia PO. BD 
T. Arkamine 0.1 MG PO/BD  
T. Orofer XT PO/OD  
T. Nodosis 500 MG PO/BID  
T. Shelcal XT PO/OD  
T. Pregaba M PO/HS  
T. MVT PO/OD 
 Fluid restriction <1.5 L/day  
Salt restriction <2 g/day  

DAY 4 ON EXAMINATION: 15/07/2025 
TEMP - 98.6 f
PULSE - 100/min regular
BP - 100/70 mm of hg
RR - 20 / min
SPO2 - 99% on RA 
CVS -S1,S2 PRESENT, NO MURMURS 
RS - BAE -PRESENT , B/L BASAL CREPTS PRESENT 
PA - SOFT , NON TENDER 
CNS - NFND 
GRBS - 108 mg/dl


TREATMENT ON 15/07/2025
T. Nicardia PO. BD 
T. Arkamine 0.1 MG PO/BD  
T. Orofer XT PO/OD  
T. Nodosis 500 MG PO/BID  
T. Shelcal XT PO/OD  
T. Pregaba M PO/HS  
T. MVT PO/OD 
 Fluid restriction <1.5 L/day  
Salt restriction <2 g/day  

DAY 5 ON EXAMINATION: 16/07/2025 
TEMP - 98.4 f
PULSE - 100/min regular
BP - 100/70 mm of hg
RR - 20 / min
SPO2 - 99% on RA 
CVS -S1,S2 PRESENT, NO MURMURS 
RS - BAE -PRESENT , B/L BASAL CREPTS PRESENT 
PA - SOFT , NON TENDER 
CNS - NFND 
GRBS - 108 mg/dl

TREATMENT ON 16/07/2025
T. Nicardia PO. BD 
T. Arkamine 0.1 MG PO/BD  
T. Orofer XT PO/OD  
T. Nodosis 500 MG PO/BID  
T. Shelcal XT PO/OD  
T. Pregaba M PO/HS  
T. MVT PO/OD 
 Fluid restriction <1.5 L/day  
Salt restriction <2 g/day  


DAY 6 ON EXAMINATION: 17/07/2025 
TEMP - 98.1 f
PULSE - 96/min regular
BP - 110/70 mm of hg
RR - 20 / min
SPO2 - 98% on RA 
CVS -S1,S2 PRESENT, NO MURMURS 
RS - BAE -PRESENT , B/L BASAL CREPTS PRESENT 
PA - SOFT , NON TENDER 
CNS - NFND 
GRBS - 118 mg/dl

ECG ON 17/07/2025 11.15 am

2D ECHO ON 17/07/2025 👇
https://youtube.com/shorts/xmT1FwbOjPU?si=DAj3ryreXk0kK7t-
INVESTIGATIONS ON 17/07/2025

  
    
  :




Date: 17/7/25

Time: 11 a.m.


DIAGNOSIS:


    

  1. CKD on MHD
    2. 

  2. Anaemia of chronic disease
    3. 

  3. Atrial fibrillation & FVR
    4. 

  4. Hep C (RFT S+)
    5. 



History:

Patient had sudden onset of palpitations, chest pain, shortness of breath during dialysis. Dialysis started at 9 a.m. today and had sudden onset of SOB and palpitations at 11 a.m. Patient had similar complaints on 14/7/25 at 6:45 p.m. during dialysis.




O/E:

Patient is conscious, agitated

Afebrile


Vitals:


    

  • PR: 162 /min
    • 

  • HR: 180 /min
    • 

  • BP: 80/60 mmHg
    • 

  • Apex pulse deficit: 18
    • 

  • RR: 46 /min
    • 

  • CVS: S1S2 +, no murmur
    • 

  • RS: B/L crepts (+)
    • 

  • PA: soft
    • 

  • CNS: NFND
    • 





Rx:


    

  1. Inj. NORAD infusion @ 2 ml/hr
    
→ Titrate to maintain MAP > 65 mmHg
    2. 

  2. Inj. Amiodarone (150 mg bolus + dose) @ 25 ml/hr
    3. 

  3. Inj. Lasix 40 mg stat (IV bolus)

TREATMENT ON  17/07/2025*
T. Nicardia PO. BD 
T. Arkamine 0.1 MG PO/BD  
T. Orofer XT PO/OD  
T. Nodosis 500 MG PO/BID  
T. Shelcal XT PO/OD  
T. Pregaba M PO/HS  
T. MVT PO/OD 
 Fluid restriction <1.5 L/day  
Salt restriction <2 g/day  

DAY 6 ON EXAMINATION: 18/07/2025 
TEMP - 98.1 f
PULSE - 140/min irregular
APEX BEAT = 160/min
APEX PULSE DEFICIT = 20
BP - 110/70 mm of hg
RR - 40 / min
SPO2 - 90% on RA 
CVS -S1,S2 PRESENT, NO MURMURS 
RS - BAE -PRESENT , B/L BASAL CREPTS PRESENT 
PA - SOFT , NON TENDER 
CNS - NFND 
GRBS - 80 mg/dl

ECG ON 18/07/2025 AT 7.20 am
INVESTIGATIONS ON 18/07/2025
TREATMENT ON  17/07/2025*
T. Nicardia PO. BD 
T. Arkamine 0.1 MG PO/BD  
T. Orofer XT PO/OD  
T. Nodosis 500 MG PO/BID  
T. Shelcal XT PO/OD  
T. Pregaba M PO/HS  
T. MVT PO/OD 
 Fluid restriction <1.5 L/day  
Salt restriction <2 g/day  

    1. . NORAD infusion @ 2 ml/hr
      
→ Titrate to maintain MAP > 65 mmHg
      2. 

    2. Inj. Amiodarone (150 mg bolus + dose) @ 25 ml/hr

DEATH SUMMARY
Diagnosis
CARDIOGENICSHOCKWITH ACUTE PULMONARY EDEMA
ATRIAL FIBRILLATION WITH FVR SECONDARY TO CAD
CHRONIC KIDNEY DISEASE
K/C/O HYPERTENSION
Case History and Clinical Findings
C/OB/LLOWERLIMBPAIN(MEDIALSIDEOFFEETSINCE1MONTH) B/L LOWER LIMB SWELLING SINCE 1 MONTH
SOBSINCE1MONTH HOPI:
PATIENTWASAPPARENTLYASYMPTOMNATIC1MONTHBACKTHENSHEDEVELOPEDB/L FEET PAIN, BURNNG RELIEVED ON REST
H/OB/LPEDELEDEMA,GRADEIIAGGRAVATEDINMORNINGRELIEVEDINWALKINGNOH/O CHEST PAIN, COUGH, SOB, GIDDINESS ,PALPITATION,HEADACHE,BURNING MICTUITION,LOOSE MOTION
PAST HISTORY
K/C/OHTNSINCE5YEARSONTABNICARDIA10MGBD TAB ARKAMINE 1MG BD
PERSONAL HISTORY
MARRIED, APPETITE NORMAL,MIXED DIET

REGULARBOWELANDBLADDER,NORMALMICTURITION,NOKNOWNALLERGIES NO PALLOR,ICTERUS,CYNOSIS,CLUBBING,LYMPHADENOPATHY,OEDEMA
TEMP98F,PR92/MIN,RR20/MINBP130/90MMHG,SPO296% SYSTEMIC EXAMINATION:-
CVS: S1,S2 HEARD
NOCARDIACMURMURS CNS: NFND RS:BAE+,NVBS+
P/A: NORMAL,NON TENDER
Investigation
LIVERFUNCTIONTEST(LFT)12-07-2025TotalBilurubin1.19mg/dlDirectBilurubin0.26 mg/dlSGOT(AST)61 IU/LSGPT(ALT) 27 IU/LALKALINE PHOSPHATASE 875 IU/LTOTAL
PROTEINS 5.9 gm/dlALBUMIN 2.68 gm/dlA/G RATIO 0.83
RFT 12-07-2025UREA 94 mg/dlCREATININE 4.0 mg/dlURIC ACID 4.9 mmol/LCALCIUM 10.1
mg/dlPHOSPHOROUS 2.0 mg/dlSODIUM 133 mmol/LPOTASSIUM 4.5 mmol/L.CHLORIDE 96
mmol/LANTI HCV ANTIBODIES (Rapid Test)RAPID 12-07-2025 Non Reactive HEPATITIS-BSURFACEANTIGEN(HBSAg)RAPIDTEST12-07-202510:45:AM
NegativeCOMPLETE URINE EXAMINATION (CUE) 12-07-2025APPEARANCE ClearREACTION
AcidicSP.GRAVITY1.010ALBUMIN++++SUGARNilBILESALTSNilBILEPIGMENTSNilPUS CELLS 10-11EPITHELIAL CELLS 3-4RED BLOOD CELLS 2-3CRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
RFT 15-07-2025UREA 99 mg/dlCREATININE 4.1 mg/dlURIC ACID 7.1 mmol/LCALCIUM 10.0
mg/dlPHOSPHOROUS 2.7 mg/dlSODIUM 134 mmol/LPOTASSIUM 4.5 mmol/L.CHLORIDE 98
mmol/LSERUM ELECTROLYTES 17-07-2025 SODIUM 136 mmol/LPOTASSIUM 4.1
mmol/LCHLORIDE 101 mmol/L
Arterial Blood Gas Analysis (ABG) 17-07-2025PH 7.31PCO2 33.4PO2 35.5HCO3 16.5St.HCO3
17.1BEB -8.5BEecf -8.5TCO2 37.0O2 Sat 56.5O2 Count 4.4LIVER FUNCTION TEST (LFT) 18-07-
2025 Total Bilurubin 1.54 mg/dlDirect Bilurubin 0.64 mg/dlSGOT(AST) 48 IU/LSGPT(ALT) 36
IU/LALKALINE PHOSPHATASE 767 IU/LTOTAL PROTEINS 5.7 gm/dlALBUMIN 1.97 gm/dlA/G
RATIO 0.53
RFT 18-07-2025UREA 84 mg/dlCREATININE 3.4 mg/dlURIC ACID 5.9 mmol/LCALCIUM 9.8
mg/dlPHOSPHOROUS 3.9 mg/dlSODIUM 135 mmol/LPOTASSIUM 4.3 mmol/L.CHLORIDE 99
mmol/LArterial Blood Gas Analysis (ABG) 18-07-2025 PH 7.16PCO2 22.6PO2 67.0HCO3
7.7St.HCO3 9.6BEB -19.4BEecf -19.3TCO2 17.7O2 Sat 85.5O2 Count 8.1
Arterial Blood Gas Analysis (ABG) 18-07-2025 06:56:PMPH 7.13PCO2 27.7PO2 118HCO3
8.9St.HCO3 10.0BEB -18.4BEecf -18.4TCO2 21.2O2 Sat 95.9

  Treatment Given(Enter only Generic Name)
SALTRESTRICTION<<1.5LIT/DAY FLUID RESTRICTION <2GM/DAY
INJNORADRENALINE250MGIN50MLNS15ML/HR INJ DOBUTAMINE 250MG IN 50ML NS AT 3.6ML/HR INJ MEDAZOLAM AT 3ML/HR
INJ NEOMOL IV 1GM SOS TABNODOSIS500MGPO/OD TAB PREGABA M PO/HS
TABSHELCALCTPO/OD TAB OROFER XT PO/OD TAB MVT PO/OD
MONITORVITALSINFORMSOS STRICT I/O CHARTING
When to Obtain Urgent Care
INCASEOFANYEMERGENCYIMMEDIATELYCONTACTYOURCONSULTANTDOCTOROR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed andtheadviceregardingpreventiveaspectsofcare,whenandhowtoobtainurgentcarehavebeen explained to me in my own language
SIGNATUREOFPATIENT/ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULIDNEYDISEASESTAGEV ON MAINTAINANCE HEMODIALYSIS WAS ADMITTED UNDER NEPHROLOGY FOR MAINTAINENCE HEMODIALYSIS ON 12/7/25 WITH FOLLOWING VITALS BP 130/90MMHG,PR 90BPM RR 20CPM SPO2 96%ON RA
Death Summary
A65YEARSOLDFEMALEWHOISAKNOWNCASEOFCHRONICKIDNEYDISEASESTAGEV ON MAINTAINANCE HEMODIALYSIS WAS ADMITTED UNDER NEPHROLOGY FOR MAINTAINENCE HEMODIALYSIS ON 12/7/25 WITH FOLLOWING VITALS BP 130/90MMHG,PR 90BPM RR 20CPM SPO2 96%ON RA

AS PATIENT CAME FOR MAINTAINANCE HEMODIALYSIS AND HER NEXT SESSION WAS DATED 14/7/25, PATIENT WENT HOME ON 12/7/25 EVENING. ON 14/7/25PATIENT CAME TO HOSPITAL WITH COMPALINTS OF SHORTNESS OF BREATH,VITALS BP 120/80,PR110BPM,RR26CPM,SPO299%ONRAECGSHOWEDINVERSIONOFTWAVESINV4- V6AND PATIENTS WAS STARTED O ANTIPLATELET THERAPY PATIENT WAS TAKEN UP DIALYSIS DURING WHICH SHE DEVELOPD HYPOTENISON (BP:90/60MMHG) INOTROP NORADRENALIN WAS STARTED AND THEN TAPERED BY 15/7/25 10AM. PATIENT ALSO DEVELOPED PAROXYSMAL ATRIAL FIBRILATION IN FAST VENTRICULAR RATE RESOLVED AFTER GIVING BOLUS DOSE OF INJ AMIODARONE (ON 14/7/25AT AROUND 10:30PM)PTIENT WAS HEMODYNAMICALLY STABLE BY 11AM ON 15/7/25. THEN ON 17/7/25 PATIENT AGAIN DEVELOPED HYPOTENSION DURING LAST 1HOUR OF HER HEMODIALYSIS SESSION. SHE WAS STARTED ON SINGLE INOTROPE.AUSCULTATION SHOWED BILATERAL DIFFUSE COARSE CREPT. ROOM AIR SATURATUIONS WERE FALLING TO 80%,OXYGEN SUPPLEMTATION,INTERMITTENT CPAP WERE STARTED. DIURETICS WERE GIVEN BY MAINTAINING. ECG SHOWED IRREGULAR R-R INTERVAL AND P WAVES ABSENT.SUGGESTIVE OF ATRIAL FIBRILATION AND PATIENT WAS STARTED ON AMIODARONE INFUSION ON 18/7/25 AT AROUND 5:40PM PATIENTWAS ELECTIVELY INTUBATED I/V/O INCREASING RESPIRATORY DISTRESS AND HYPOXIA DESPITE NON INVASIVE VENTILATION DUE TO PERSISTENT HYPOTENSION PATIENT WAS STARTED ON SECOND INOTROPIC AGENT
AT AROUND 8:0PM PATIENT DEVELOPED SUDDEN BRADYCARDIA CENTRAL AND PERIPHERALPULSEWERAABSENTCPRWASINITATEDFOR30MINDESPITEABOVEALL RESUSCITATORY EFFORTS PATIENT COULDNT BE REVIVED AND DECLARED DEAD AT 9:0PM ON 18/7/25 AFTER ECG SHOWED FLATE LINE
IMMEDIATE CAUSE OF DEATH
TYPEIRESPIRATORYFAILURESECONDARYTOACUTEPULMONARYEDEMA CARDIOGENIC SHOCK
ANTECEDENT CAUSE OF DEATH
HEARTFAILUREWITHPRESERVEDEJECTIONFRACTIONWITHATRIALFIBRILLATION SECONDARY TO CORONARY ARTERY DISEASE
CHRONICKIDNEYDISEASE K/C/O HYPERTENSION
Discharge Date Date:19/07/25 Ward:NEPHROLOGY





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