M & M CASE PRESENTATION

DR.GADDE VAMSI KRISHNA

2nd YEAR POST GRADUATE

DEPARTMENT OF GENERAL MEDICINE

CHIEF COMPLAINTS

• A 65 year old male farmer by occupation chronic alcoholic since 40 years was brought to casualty in a state of altered sensorium with h/o
• Fever since 2-3 days associated with cough , SOB and generalised weakness
• Irrelevant talk and drowsiness since 1 day

HISTORY OF PRESENT ILLNESS

• H/o binge drinking since 4-5 days without taking food
• Fever (low grade,intermittent) since 2-3 days associated with dry cough , SOB & generalized weakness
• Irrelevant talk and drowsiness since 1 day
• No h/o headache/vomiting/seizures
• No h/o pain abdomen/loose stools
• No other complaints

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PAST HISTORY

• H/O similar episode in the past 4 months back which resolved with conservative treatment (no documentation available)
• Surgery for Right Femur Fracture 6 months back
• Not a k/c/o of DM/HTN/TB/Asthma/Epilepsy/CAD

PERSONAL HISTORY

• Appetite - decreased
• Sleep - adequate
• Bowel & Bladder – regular
• Chronic smoker since 40 yrs (4-5 chutta/day)
• Chronic alcoholic since 40 yrs (90-180ml/day)

GENERAL EXAMINATION

• PATIENT DROWSY BUT AROUSABLE
• Not oriented to Time / Place / Person
• Temp : 100F
• PR : 141
• BP : 110/70mmhg
• RR : 20cpm
• GRBS: 146 mg/dl
• ICTERUS +
• No pallor,cyanosis,clubbing,oedema,generalised lymphadenopathy

SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM:

• GCS : E3 V2 M4
• Not oriented to T/P/P
• Pupils: NSRL
• No signs of meningeal irritation
• Motor system - All superficial & deep reflexes present & normal
• Power : spontaneously moving all 4 limbs
• Tone: Normal in all 4 limbs
• Sensory system: Not able to perform

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SYSTEMIC EXAMINATION

• CRANIAL NERVE EXAMINATION
• 1- not able to test
• 2- not able to test
• 3,4,6- intact
• 5- not able to test
• 7- intact
• 8- not able to test
• 9- intact
• 10- intact
• 11- not able to test
• 12- not able to test

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

• Elliptical & b/l symmetrical chest
• No visible pulsations/engorged veins/ scars/sinuses on the chest wall
• Apex beat palpable at 5th intercostal space medial 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 bilateral IAA & ISA

SYSTEMIC EXAMINATION

PER ABDOMEN:

• Obese
• No visible pulsations/engorged veins/scars/sinuses
• Soft , tenderness + in right hypochondrium & epigastric region
• Hepatomegaly + (liver span: 16 cms)
• No other palpable mass
• Bowel sounds present

INVESTIGATIONS

• ECG

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INVESTIGATIONS

• Chest X-ray

INVESTIGATIONS

INVESTIGATIONS

INVESTIGATIONS

INVESTIGATIONS

INVESTIGATIONS

INVESTIGATIONS

PT: 17 sec

INR: 1.2

APTT: 34 sec

S.Amylase: 33 IU/L

S.Lipase: 18 IU/L

Serology: HCV - Reactive

Rapid Dengue: Negative

MP strip: Negative

Covid RTPCR: Negative

INVESTIGATIONS

USG ABDOMEN:

• Increased size & altered echotexture of liver
• Altered echotexture of pancreas with dialted MPD

2D ECHO:

• EF: 58%
• No RWMA , No AS/MS
• Trivial AR+/TR+
• Sclerotic AV , No PAH , No PE / LV clot
• Diastolic dysfunction +
• IVC size: 1.4 cms

PROVISIONAL DIAGNOSIS

• TYPE -1 RESPIRATORY FAILURE ? COMMUNITY ACQUIRED PNEUMONIA
• ? ALCOHOLIC DELIRIUM / HEPATIC ENCEPHALOPATHY
• ALCOHOLIC / VIRAL (HEP-C) HEPATITIS

TREATMENT

• IV FLUIDS 0.9%NS CONTINUOUS @ 75 ml/HR
• INJ.CEFTRIAXONE 1 gm IV/BD
• TAB.AZITHROMYCIN 500 mg/OD
• INJ.PAN 40 mg IV/OD
• INJ.THIAMINE 1amp IN 100ml IV/TID
• INJ.OPTINEURON 1amp IN 100ml IV/OD
• TAB.PCM 650 mg TID
• SYP.LACTULOSE 15 ml/HS
• NEB WITH IPRAVENT AND BUDECORT – 6^TH HOURLY
• HEAD END ELEVATION & O2 INHALATION @ 3-4 Lit TO MAINTAIN SpO2 >92%
• TAB.OLANZEPINE 5 mg/HS
• BP/PR/TEMP/SPO2 MONITORING

• Patient improved drastically over night & on 11/08/2021 at 1:30 pm ,patient started having tachypnea with respiratory rate of 44cpm & suddenly developed weakness of right upper limb and lower limb with GCS of 3/15 (E1 V1 M1).
• On suspicion of CVA IC bleed/ Acute infarct CT brain was done which turned out to be normal
• At 6.30 pm in view of poor GCS & falling saturations with feeble central pulses patient was intubated but he had bradycardia and was asystolic for which cpr was initiated according to 2015 AHA guidelines & continued for 6 cycles.
• Despite of the resuscitative measures patient could’nt be revived and ECG showed no electrical activity and patient was declared dead at 7:36pm on 11/8/2021 

DEATH SUMMARY

• A 65 yr old male presented to casuality on 10/8/21 with altered sensorium with GCS of 9/15 (E3 V2 M4)
• patient attenders gave a history of increased intake of alcohol 6 days with out food intake and integrating the history and clinical presentation a working diagnosis of delirium secondary to ? Alcohol intoxication / ? Hepatic encephalopathy and Type -1 respiratory failure secondary to ? CAP patient was given supportive treatment with vitals being stable.
• Patient improved symptomatically over time.

DEATH SUMMARY

• on 11/08/2021 at 1:30 pm patient started having tachypnoea with respiratory rate of 44cpm and suddenly developed weakness of right upper limb and lower limb with worsening GCS: E1 V1 M1 & BP of 110/70 mmhg
• On suspicion of CVA IC bleed/ Acute infarct CT was done which turned out to be normal
• At 6.30 pm in view of poor GCS & falling saturations with no recordable bp , feeble central pulses patient was intubated but he had bradycardia and was asystolic for which cpr was initiated according to 2015 AHA guidelines & continued for 6 cycles.

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DEATH SUMMARY

Despite of the resuscitative measures patient could’nt be revived and ECG showed no electrical activity and patient was declared dead at 7:36pm on 11/8/2021.

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IMMEDIATE CAUSE OF DEATH :

• ? CVA - ACUTE INFARCT INVOLVING BRAIN STEM

ANTECEDENT CAUSE OF DEATH :

• TYPE 1 RESPIRATORY FAILURE SECONDARY TO ? COMMUNITY AQUIRED PNEUMONIA
• ? ALCOHOLIC DELIRIUM/HEPATIC ENCEPHALOPATHY
• ALCOHOLIC / VIRAL (HEP-C) HEPATITIS

THANK YOU