MORNING REVIEW

GASTROENTEROLOGY UNIT
ADMISSIONS ON THURS28/10/2021
S/N NAME AGE SEX DIAGNOSIS OUTCOME
1 O.T 57YRS M ACUTE PULMONARY DIED 2DOA
EMBOLISM 2º HEMATOLOGICAL
MALIGNANCY
2 E.T 58YRS F SEPSIS FOCUS GI COMPLICATED DIED FEW
BY AKI HOURS AFTER
ADMISSION

3 OO 56YRS F ACUTE GASTROENTERITIS DIED 2DOA

COMPLICATED BY AKI,ARDS
WITH PARALYTIC ILEUS
4 C.T 72YRS F ANAEMIA ?? CAUSE KIV CKD ON ADMISSION

5 AA 38YRS M ACUTE GASTROENTERITIS ON ADMISSION

COMPLICATED BY AKI
 .
6 BO 74YRS F LEFT HEMISPHERIC DIED 3DOA
HAEMORRHAGIC CVA
COMPLICATED BY ASPIRATION
PNEUMONITIS
7 AJ 45YRS M DECOMPENSATED CLD 2º CHBV ON ADMISSION
COMPLICATED BY
HEPATORENAL SYNDROME
8 AR 53YRS M SEVERE ANAEMIA ?CAUSE R/O ON ADMISSION
HEMATOLOGICAL
MALIGNANCY
9 OI 58YRS F CAP R/O COVID 19 PNEUMONIA ON ADMISSION
.
10 47YRS M LEFT DMFS GRADE IV ON ADMISSION
 BIODATA
• NAME: O.T.
• AGE: 57yrs
• SEX: M
• OCCUPATION: Engineer
• MARITAL STATUS: Married
• ADDRESS: Ikorodu
• RELIGION: Christian
• TRIBE: Yoruba
 PRESENTING COMPLAIN
• Generalized body weakness × 1/52
• Breathlessness x 3/7
 History of Presenting complain
• A known hypertensive of ? duration, not a known diabetic or
asthmatic who was apparently well until one week ago when he
suddenly started feeling weak. Weakness had progressively
increased till presentation, severe enough to prevent him from
his daily activities.
• He suddenly became breathless while at work 3 days ago.
Breathlessness was present at rest.
• No history of orthopnea, PND, cough, chest pain, palpitations,
pedal oedema.
 .
• No history of differential leg swelling, calf pain, long distance
travel, hemoptysis, weight loss, fracture, recent surgery or
recent prolonged hospital admission. Has never had DVT/PE.
• Ass hx of bilateral redness of the eyes which was noted about
10 days PTP, no ass itching, tearing, proptosis or trauma to the
eyes.
• Ass hx of easy fatiguability and dizziness but no syncopal
attacks.
 .
• No history of fever, night sweats or contact with person with
chronic cough.
• No history of oliguria, frothiness of urine, nocturia, hiccups,
early morning facial puffiness or pedal oedema.
• No history of abdominal pain, abdominal swelling, vomiting,
diarrhea, constipation, yellowness of the eyes, passage of pale
bulky stool, melena or hematemesis.
 .
• No history of headache, seizures or loss of consciousness.
• No history of hesitancy, post micturition dribbling,
intermittency or straining.
• No history of bleeding from any part of the body
• No history of bone pain, photosensitivity or rashes.
 .

• No hx of exposure to petrochemicals or radiation, MSP0

• Doesn’t live in areas of high altitude
• Has had 2 doses of COVID vaccine
• He presented to a private hospital after onset of breathlessness
but was referred to LASUTH when there was no improvement
in clinical symptoms.
PMHX / PSHX
• Genotype AA, HTN+, DM°, Asthma°, PUD°, Epilepsy°
• Arthritis + x5years
• Nil recent blood transfusion
• Nil recent admission outside index illness.
• PSHx: Nil
DRUG AND ALLERGY HX:
• Atenolol, lisinopril, amlodipine, moduretic
• Paracetamol, diclofenac,
• Prednisolone
• No known drug allergy.
FAMILY AND SOCIAL HISTORY
 Married in a monogamous setting with 3 children.
 No family history of diabetes, hypertension, cardiovascular
disease or CA.
 Doesn’t take alcohol or cigarette.
 Takes herbal concoction (water and alcohol based).
SUMMARY
• Mr O.T. a 57 year old engineer who presented with
progressive generalized body weakness of 1 week duration
and sudden onset breathlessness of 3 days duration.
• +ve hx of redness of both eyes
• No history of cough, chest pain, oliguria, frothiness of
urine, leg swelling, abdominal swelling, immobilization,
weight loss and no history of fever.
DIFFERENTIALS
• Acute pulmonary embolism
• Community acquired pneumonia
• COVID 19 pneumonia
• Acute exacerbation of asthma
• Congestive cardiac failure
ON EXAMINATION
Middle aged man, in respiratory distress, afebrile, not pale, anicteric, dehydrated, not cyanosed,
no finger clubbing, no pedal edema with inguinal lymphadenopathy, marked erythema in both
palms and soles and bilateral conjunctival hyperaemia.
Admitting vitals
 Pr- 84b/m
 Bp- 124/89mmhg
 RR- 28c/m
 Spo2- 90% on RA
 RBS - 94mg/dl
 T - 37.10c
CHEST

 RR- 30c/m

 SPO2- 92% on 11L 02 via NRFM

 Trachea was central

 Equal chest expansion

 Resonant percussion notes in  all lung zones

 Coarse crepitations in the RM and LLZ

CVS
 PR- 120bpm, full volume, regular

 No TAW No LCMB

 BP- 117/80mmHg

 JVP- not elevated

 AB – 5LICS, MCL

 HS- S1S2 only

ABDOMEN
 Distended, MWR

 tenderness in the right hypochondrium.

 Liver is 6cm below the RCM, smooth, tender

 Spleen- tipped K2°

 Ascites°

 DRE: Good perineal hygiene, no mass felt, examining finger stained with brown stool.
CNS
 Conscious and alert

 Oriented in TPP

 Pupils are 3mm bilaterally reactive to light

 No signs of meningeal irritation

 No obvious CN palsy

 Normal tone, power and reflexes globally

 No asterixis.
SUMMARY
• Mr O.T. a 57 year old engineer who presented with progressive generalized body weakness of
1 week duration and sudden onset breathlessness of 3 days duration.
• +ve hx of bilateral redness of both eyes
• No history of cough, chest pain, oliguria, frothiness of urine, leg swelling, abdominal swelling,
immobilization, weight loss and no history of fever.
 Examination findings include obvious respiratory distress, dehydration, tachycardia,
tachypnoea, reduced oxygen saturation and RM&LLZ coarse crepitations, tender
hepatosplenomegaly, inguinal lymphadenopathy, conjuctival hyperaemia and erythema of both
palms and soles.
ASSESSMENT
 Acute pulmonary embolism 20 ? Hematological malignancy (well score – 4.5)
 Differentials:
 Community acquired pneumonia
 R/o Covid19 pneumonia
PLAN
 Admit
 FBC, ESR, EUCR, LFT, FLP, ca2+, phosphate, uric acid
 Viral markers, Urinalysis
 Peripheral blood film
 D dimer, clotting profile
 Doppler USS of both lower limbs
 Abdominal pelvic USS
 CTPA
 Tumour markers ( Ca 19.9, AFP, CEA, PSA)
 CXR, ECG, ECHO
.
 Cardiac enzymes, BNP
 Covid 19 screening
 SC clexane 60mg 12hrly
 IVF N/S 500mls 12hrly
 IV Augmentin 1.2g 12hrly
 IV flagyl 500mg 8hrly
 Strict I/o monitoring
 Supplemental o2 via NRFM @15L/ min
INVESTIGATIONS
FBC (28/10)
FBC (27/10) PCV- 69%
WBC- 25.5 x 10^9/L
 PCV- 52.2%
(N-80%, L-15%)
 WBC- 7.9 x 10^9/L (N- PLT- 517 x 10^3/L
87.2%, L-6.2%) ESR – 10 mm/hr
 PLT- 414 x 10^3/L
 ESR – 3mm/hr
.
E/u/cr (27/10)
K +- 5.1 mmol/L E/U/Cr (28/10)

 Na-132mmol/l
K +- 7.7 mmol/L
Na-119mmol/l
 Cl-106 mmol/l
Cl- 81 mmol/l
 HCO3- 18mmol/l
HCO3- 33 mmol/l
 Urea- 180mg/dl Urea- 95 mg/dl

 Cr –5.5 mg/dl
Cr –4.1 mg/dl
.
 ECG – sinus tachycardia
 Covid 19 screening (27/10) negative
 D dimer  10 ug/ml (0-0.5)
 Cardiac enzymes
 Ckmb 2.2ng/ml (RV <5.0ng/ml)
 TnI 0.1 ng/ml (RV < 0.5ng/ml)
 Myo 138ng/ml (RV 70.0ng/ml)
ASSESSMENT
 Myloproliferative disorder likely Polycythemia Vera complicated by acute pulmonary
embolism (well score – 4.5) and AKI with severe hyperkalaemia.
PLAN
 10mls of 10% calcium gluconate over 10mins
 IV soluble insulin 10IU + 50mls of 50% D/W in 1:1 dilution
 4hrly RBS check
 Repeat e/u/cr in another lab
 For possible hemodialysis after review of repeat e/u/cr
 Repeat FBC in another lab
 Peripheral blood film
 Consult to hematologist
 Consult to nephrologist
UPDATE
 Few hours later, patient started gasping and all attempts to rescucitate him proved abortive
 Plan: transfer morgue for autopsy