M & M CASE PRESENTATION

DR.GADDE VAMSI KRISHNA

1^ST YEAR POST GRADUATE

DEPARTMENT OF GENERAL MEDICINE

CHIEF COMPLAINTS

• 69 year old male came to the hospital on 16/6/21 in a state of drowsy but arousable with chief complaints of:
• Fever & 2 episodes of vomiting at yesterday night
• Pain abdomen & abdominal distension , SOB , Generalised weakness since today morning.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic until yesterday night when he had a binge of alcohol following which he had 2 episodes of non bilious , non projectile vomiting & low grade fever which were releived with some symptomatic treatment.

Next day morning he had pain abdomen (diffuse) , abdominal distension , SOB (grade II – III) & generalised weakness for which he came to our hospital.

No h/o loose stools / obstipation

No h/o chest pain / palpitations / syncopal attacks / cough

No h/o decreased urine output / burning mmicturition

No other complaints

PAST HISTORY

• K/c/o HTN since 5 yrs and was on treatment
• Not a k/c/o DM/Asthma/Epilepsy/TB
• H/o chest pain & SOB 5 yrs back for which he went to a hospital in hyderabad where he was diagnosed to be havimg some heart problem and symptomatic treatment was given (no records available).

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PERSONAL HISTORY

• Appetite - decreased
• Sleep - adequate
• Bowel & Bladder – regular
• Chronic smoker since 40 yrs
• Chronic alcoholic since 20 yrs

GENERAL EXAMINATION

• Patient was drowsy but arousable , coherent and cooperative 
• JVP raised
• No pallor / icterus / cyanosis / clubbing / koilonychia / lymphadenopathy / pedal edema
• Temp: afebrile to touch
• PR: 78bpm 
• BP: 110/70 mm hg 
• SpO2: 98% on RA 

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

• Elliptical & b/l symmetrical chest
• No visible pulsations/engorged veins/ scars/sinuses on the chest wall
• JVP raised
• Apex beat palpable at 6th intercostal space lateral to midclavicular line
• S1 , S2 heard
• No murmurs

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM:

• Shape of chest elliptical, b/l symmetrical
• Trachea appears to be central
• Expansion of chest equal on both sides
• B/l air entry +, normal vesicular breath sounds
• Fine crepts + in right IAA & ISA.

SYSTEMIC EXAMINATION

PER ABDOMEN:

• Distended
• No visible pulsations/engorged veins/scars/sinuses
• Soft , non tender
• Bowel sounds present

SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM:

• Higher mental functions intact
• Sensory system - normal
• Motor system - normal
• Cranial nerves - intact

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30 MIN LATER

• GCS worsened - patient became unresponsive
• Feeble peripheral pulses 
• BP: systolic 50 mmhg on palpation

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• CVS: S1, S2 muffled 
• RS: BAE + , NVBS , Fine crepts + in right IAA & ISA
• P/A: soft, distended, sluggish bowel sounds heard, no guarding / rigidity 

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INVESTIGATIONS

INVESTIGATIONS

INVESTIGATIONS

TROPONIN-I : Negative

2D ECHO :

• Global hypokinesia
• Dilated LA/LV 
• EF : 27% 
• TR with Mild PAH + 
• RVSP-40 mmhg
• Diastolic dysfunction + 
• IVC : 1.35cms

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INVESTIGATIONS

• HB : 11.5 gm/dl
• TLC 29,700 
• PLATELETS : 1.85 lakhs

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• PT : 17 sec
• INR :1.2 
• APTT :33 sec

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• UREA : 44 
• CREATININE : 1.3
• Na+ - 135 
• k+ - 4.1 
• Cl- 98 

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INVESTIGATIONS

DIAGNOSIS

• HFrEF SECONDARY TO ?CAD 
• CARDIOGENIC SHOCK WITH REFRACTORY HYPOTENSION 
• RIGHT SIDED PNEUMONIA 
• K/C/O HYPERTENSION SINCE 1.5 YEARS 

TREATMENT GIVEN

• Nill by mouth till further orders 
• IVF- 1 NS IV/bolus given; 0.9% NS continuous infusion .

U.0+30ml/hr 

• Inj.NORADRENALINE 2amp in 48 ml NS @ 12 ml/hr (0.48 mg/hr)
• Inj.DOBUTAMINE 1 amp (1ml=1000mcg) in 45 ml NS @ 4 ml/hr .

(20mg/hr) (increase or decrease according to MAP~65-70mmhg)

• Inj.AUGMENTIN 1.2gm/IV/BD 
• Inj.THIAMINE 1 amp in 100ml NS /IV/TID 
• Inj.PAN 40mg/IV/OD 
• Monitor BP, PR,RR 
• STRICT I/O Charting 

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• RT aspirate showed 100 ml of bile
• Surgery referral was taken in v/o pain abdomen and abdominal distention.
• DRE: anal spincter tone: normal, rectum loaded, gloved finger stained with fecal matter, 
• Advised x-ray abdomen supine.
• No active surgical intervention.

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CPR & INTUBATION

• Inspite of the maximum dose of inotrope support patient continued to be in hypotension .

and at 4:00 AM on 17/6/21 patient suddenly became unresponsive with no recordable

PR/BP/SpO2. 

• CPR was initiated acc. To 2015 AHA guidelines and patient was intubated with ET 7.0 
• 4:00AM BP/PR - NR- CPR Initiated, INJ ADRENALINE 1MG IV/ STAT 
• 4:05AM BP/PR - NR - CPR Continued , INJ ADRENALINE 1MG/ IV STAT 
• 4:10 AM BP/PR - NR - CPR Continued , INJ ADRENALINE 1MG/ IV STAT 
• 4:15 AM BP/PR - NR - CPR Continued , INJ ADRENALINE 1MG/ IV STAT 
• 4:20 AM BP/PR - NR - CPR Continued , INJ ADRENALINE 1MG/ IV STAT 
• 4:25 AM BP/PR - NR - CPR Continued , INJ ADRENALINE 1MG/ IV STAT 
• 4:30 AM BP/PR - NR 
• Despite of the above resuscitatiove measures patient couldn't be revived and declared

dead at 4:37 AM on 17/6/21.

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DEATH SUMMARY

• 69/m came to casuality on 16/6/21 at 3:00 pm with c/o fever and 2 .

episodes of vomiting yesterday night f/b pain abdomen , SOB (grade

2-3) and altered sensorium since 16/6/21 morning.

• Inotropes were started in v/o hypotention.
• ECG showed non specific ST-T changes with ST elevations noted in .

Lead 2,3,AvF with reciprocal changes in Lead I,AvL,V5,V6.

• 2D ECHO : global hypokinesia , dilated LA/LV ,EF : 27% , TR with .

mild PAH + , RVSP-40

• Troponin- I : Negative 
• Symptomatic treatment was given.

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DEATH SUMMARY

• Surgery referral was taken in v/o pain abdomen and abdominal distention
• Advised x-ray abdomen supine which came out to be normal.
• So no active surgical intervention.
• On 17/6/21 at 4:00 AM patient suddenly became unresponsive with no recordable BP/PR/SpO2.
• CPR was initiated acc to 2015 AHA guidelines and continued for 6 cycles.
• Despite of all the resuscitative measures, patient couldn't be revived and declared dead at 4:37 AM on 17/6/21.

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DEATH SUMMARY

IMMEDIATE CAUSE : 

• CARDIOGENIC SHOCK WITH REFRACTORY HYPOTENSION

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ANTECEDENT CAUSE : 

• HFrEF SECONDARY TO ?CAD , RIGHT SIDED PNEUMONIA, K/C/O HTN

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THANK YOU