65 year old male ,farmer by occupation was brought to the casuality

             in an altered state with a low G C S  since 1 day.
             involuntary movements involving left UL and LL since 1day.
              slurred speech since 1day.
In view of low gcs patient was intubated and put on ventilator (ACMV/ VC )
On history taken from the attendars ,he is a. chronic alcoholic consumes almost 90ml/day and occasional smoker ,farmer by occupation who works hard enough under scrotching sun to earn his daily bread , this man was apparently asymptomatic 4yrs back then

IN  2016was diagnosed with diabetes mellitus when he visited the hospital with complaints of low grade fever   then on  was on oral hypoglycemic agents for 2months later on was shifted to insulin injections as his sugars weren’t under control with OHA.

IN 2017   he revisited hospital with complaints of pedal oedema extending upto knees and facial puffiness ,neck pain ,on evaluation he was found to be hypertensive and his renal parameters were deranged,as the patient denied admission ,was put on supportive treatment (?LASIX) and sent home.

IN JANUARY 2018  He developed slurring of speech with slight deviation of mouth after intake of binge of alcohol  following which he visited nearby hospital ,advised for an MRI brain which showed  infarcts as told by the attendars ,was put on medication (??) and he recovered within a day,

Due to repeated visits to the hospital ,he completely gave up alcohol as he must have thought that alcohol could  be a triggering factor for his morbidities which could possibly be true.

IN AUGUST  2018  He again visited hospital with complaints of
                 fever of high grade since 4 days
                 decreased urine output
                  neck stiffness
He was admitted and on evaluation his
      sugars were high,
      CUE showed albumin 2+,sugars 3+,pus cells plenty appearance cloudy
       Hba1c  8.

       Urine for ketone bodies negative
      ESR 110mm
      blood urea 108
      ser creatinine 3.7
      USG abdomen bilateral RPD changes grade 3
      serum albumin 2.7
      xray cervical spine findings were consistent with spondylitis
Provisional diagnosis of DIABETIC NEPHROPATHY with UNCONTROLLED SUGARS and with DIABETIC FOOT was made ,was in hospital for 5days ,sugars and bp was under check,was put on supportive management and was discharged at request.
and then on 16th of APRIL 2019,  presented to us in an altered state
On examination:
CNS :
stuporous state,slurred speech,E2 V1 M4 ,tone normal,reflexes only ankle was elicitable ,plantars had withdrawal response, no signs of cerebellar irritation.
Intermittent involuntary movements involving left lower limb.
Neck stiffness with complete loss of neck movement .
RESPIRATORY SYSTEM :

on inspection: decreased lung expansion on left side
on palpation : consistent with inspectory findings.
on percussion: dullness noted in the basal areas
on auscultation : crepts noted in the lower areas.
OTHER SYSTEMS were normal
INVESTIGATIONS SEND ON THE DAY OF ADMISSION
RBS 743.
USG abdomen showed no abnormality
FBS 76
PLBS 153
Hba1c 6.5
HIV,HBS,HCV negative
serum osmolarity 320

In view of mixed acidosis and raised renal parameters patient was taken for dialysis ,which improved postdialysis ,involuntary movements subsided as well ,for  raised counts ,he was started on CEFTRIAXONE iv but then the counts werent under controlled hence the antibiotics was escalated to iv MEROPENEM,was put on inotropic support as his bp was falling,  Patient was continued on mechanical ventilation as his saturations were maintaining only with Intermittent Positive Pressure Ventilation(IPPV) ,effort was made to wean off the patient from ACMV to SIMV to CPAP as the patient was able to take spontaneous breaths,Tracheostomy tube was secured on 29th of april ,currently the patient is on CPAP with volume controlled ventilation with TT secured.

Trend of leucocyte count

culture report

His sugars were under control with insulin injections regularly, electrolyte disturbances were corrected,despite which patient sensorium wasnt improving, hence intracranial pathology was suspected and MRI brain and EEG  was advised.

none of the above imaging helped in exploring the cause for his altered sensorium, EEG showed beta waves which suggest a very bad prognosis, the patient is on mechanical ventilation on CPAP VC mode,on trachestomy tube,his renal parameters are under check only with regular dialysis ,due to his prolong bedridden condition patient was  recieving complete supportive care,
He developed anasarca,repeat LFT showed hypoalbuminemia ,albumin dropped from 3.0 to 1.7.

He was combating  between life and death,inspite of having explained the poor prognosis of the patient to the attendars ,they still had hopes and were quite supportive, patient  was on ventilator for almost 25days ,as care givers we left no stone unturned to bring this patient out of his coma ,but death is something inevitable ,
on 11th of MAY 2019  since morning the condition of the patient was deteriorating ,basic investigations were advised,

HEAMOGRAM showed pancytopenia picture
Blood urea           : 151
Serum creatinine  : 2.6
ABG was showing severe metabolic acidosis.

We again explained the bad prognosis to the attendars as the patient developed ARDS quite evident from the chest xray above , planned to move ahead with more aggressive treatment but then the attendars did not give consent as they lost hopes and wanted a peaceful death.
Eventually in the evening the patient's cardiac activity stopped following which he could not be revived and was declared dead.
So if we  review the entire history of this patient , still there are lot of doubts which are clinching our brains , though we know the immediate cause of death ,we are still not sure of the antecedent cause of death, and when we ourselves are not sure of it then how can we explain it to the patient attendars which is there right to know,
Is there something which we could have done prior which must have save this old man ,
the reason for making this blog is to review and rereview the history and the course of events occured during his stay in the hospital so that we could find answer to our every single doubt and can hopefully execute it on other patients,   many of the queries are still unanswered.

Kindly drop your comments.

POINTS OF DISCUSSION AROUND THIS PATIENT:

1)  What could be the  possible causes of  Generalised edema?
2)  Did the ongoing hypoalbuminemia led to his anasarca?
3)Indications of iv albumin and how far is it beneficial in this patient?