1 of 34

M & M CASE PRESENTATION

DR.GADDE VAMSI KRISHNA

2nd YEAR POST GRADUATE

DEPARTMENT OF GENERAL MEDICINE

2 of 34

CHIEF COMPLAINTS & HOPI

  • A 70yr old male, farmer by occupation was brought to casualty on 17/8/21 in an unconscious state.
  • According to attenders patient was apparently asymptomatic 1 week back and then he started Binge drinking for 2 days followed by fever (low grade,intermittent,reduced with medications) and abdominal pain (burning type,diffuse more in the epigastric region) for which he went to a local RMP and got treated.

​

3 of 34

CHIEF COMPLAINTS & HOPI

  • 3 days later he developed generalized weakness and was unable to do his routine activities for which he was admitted to local hospital where he was diagnosed to have DENGUE (NS1 ANTIGEN Positive) and Platelet Count was 24,000.
  • Symptomatic treatment was given and as he wasn’t responding to commands and became unconscious since yesterday night he was brought here to our hospital on 17/8/21.

4 of 34

PAST HISTORY

  • No similar complaints in the past
  • Not a k/c/o of DM/HTN/TB/Asthma/Epilepsy/CAD

5 of 34

PERSONAL HISTORY

  • Appetite - decreased
  • Sleep - adequate
  • Bowel & Bladder – regular
  • Chronic Alcoholic since 30 years (90-180 ml/day)
  • Chronic smoker since 20 yrs (2-3 beedi per day)

6 of 34

GENERAL EXAMINATION

  • PATIENT IS IN STUPOUROUS STATE
  • GCS : E1 V1 M1
  • Temp : 99 F
  • PR : 141 bpm
  • BP : 70/40 mmhg
  • RR : 36 cpm
  • SpO2: 78% on RA
  • GRBS: 34 mg/dl
  • ICTERUS +
  • No pallor,cyanosis,clubbing,oedema,generalised lymphadenopathy

7 of 34

SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM:

  • GCS : E1 V1 M1
  • Pupils: NSRL
  • No signs of meningeal irritation
  • Motor system - All superficial & deep reflexes present & normal
  • Sensory system: Not able to examine
  • Cranial nerves 7 , 9 & 10 - Intact , Rest not able to examine
  • Brain stem reflexes: Intact

​

8 of 34

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

9 of 34

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 +, Diffuse wheeze +
  • Fine crepts + in bilateral IAA & ISA

10 of 34

SYSTEMIC EXAMINATION

PER ABDOMEN:

  • Obese
  • No visible pulsations/engorged veins/scars/sinuses
  • Soft , no organomegaly
  • Bowel sounds present

11 of 34

INVESTIGATIONS

ABG:

  •  PH 7.30
  •  PCO2 24.9
  •  PO2 61.8
  •  HCO3 11.9
  •  St.HCO3 14.5
  •  BEB -12.9
  •  BEecf -13.3
  •  TCO2 24.7
  •  O2 Sat 76.2
  •  O2 Count 7.4

​

12 of 34

RESUSCITATION

  • IV Fluids 4 units NS IV/BOLUS
  • INJ.25% Dextrose IV/STAT
  • Head end elevation & O2 inhalation to maintain SpO2 > 92%
  • In v/o poor GCS & falling saturations patient was intubated with ET 7.0 and connected to mechanical ventilator
  • MODE: ACMV-VC
  • FiO2: 100%
  • PEEP: 5cm H2O
  • RR: 14 cpm
  • VT: 420 ml

13 of 34

POST RESUSCITATION

On Examination:

  • GCS: E2 VT M4
  • PR: 130 bpm
  • BP: 100/60 mmhg
  • SpO2: 99 %
  • GRBS: 342 mg/dl
  • CVS: S1 S2 + , No murmurs
  • RS: BAE+ , NVBS , Fine crepts + in bilateral IAA & ISA
  • P/A: Soft , BS+

14 of 34

INVESTIGATIONS

CT-BRAIN: No significant abnormality

​

ABG:

  •  PH 7.30
  •  PCO2 24.9
  •  PO2 93.0
  •  HCO3 14.5
  •  St.HCO3 11.9
  •  BEB -12.9
  •  BEecf -13.3
  •  TCO2 24.7
  •  O2 Sat 94.9
  •  O2 Count 15.5

15 of 34

INVESTIGATIONS

  • ECG

16 of 34

INVESTIGATIONS

CHEST X-RAY:

17 of 34

INVESTIGATIONS

HEMOGRAM:

  • HB - 10.6 GM/DL
  • TOTAL COUNT - 13800 CELLS/CUMM
  • NEUTROPHILS - 72% , LYMPHOCYTES - 18% , EOSINOPHILS – 02% , MONOCYTES – 08% , BASOPHILS - 00%
  • PCV - 30.1 VOL%
  • MCV - 88.5 FL
  • MCH - 31.2 PG
  • MCHC - 35.2%
  • RDW-CV - 18.0%
  • RDW-SD - 58.0 FL
  • RBC COUNT - 3.40 MILLIONS/ CUMM
  • PLATELET COUNT - 25000 LAKHS/CUMM
  • SMEAR: NORMOCYTIC NORMOCHROMIC ANEMIA WITH LEUCOCYTOSIS AND THROMBOCYTOPENIA

18 of 34

INVESTIGATIONS

COMPLETE URINE EXAMINATION (CUE) :

  •  COLOUR Pale yellow
  •  APPEARANCE Clear
  •  REACTION Acidic
  •  SP.GRAVITY 1.010
  •  ALBUMIN +
  •  SUGAR Nil
  •  BILE SALTS Nil
  •  BILE PIGMENTS Nil
  •  PUS CELLS 4-6
  •  EPITHELIAL CELLS 2-4
  •  RED BLOOD CELLS Nil
  •  CRYSTALS Nil
  •  CASTS Nil
  •  AMORPHOUS DEPOSITS Absent
  •  OTHERS Nil

19 of 34

INVESTIGATIONS

LIVER FUNCTION TEST (LFT):

  •  Total Bilurubin 6.89 mg/dl
  •  Direct Bilurubin 2.10 mg/dl
  •  SGOT(AST) 488 IU/L
  •  SGPT(ALT) 158 IU/L
  •  ALKALINE PHOSPHATE 310 IU/L
  •  TOTAL PROTEINS 5.1 gm/dl
  •  ALBUMIN 1.89 gm/dl
  •  A/G RATIO 0.59

​

20 of 34

INVESTIGATIONS

RFT:

  •  UREA 113 mg/dl
  •  CREATININE 3.2 mg/dl
  •  URIC ACID 9.8 mg/dl
  •  CALCIUM 10.2 mg/dl
  •  PHOSPHOROUS 5.0 mg/dl
  •  SODIUM 140 mEq/L
  •  POTASSIUM 3.5 mEq/L
  •  CHLORIDE 104 mEq/L �

21 of 34

INVESTIGATIONS

ABG:

  •  PH 7.25
  •  PCO2 36.0
  •  PO2 99.2
  •  HCO3 19.5
  •  St.HCO3 18.7
  •  BEB -7.0
  •  BEecf -6.5
  •  TCO2 41.5
  •  O2 Sat 97.7
  •  O2 Count 14.8

​

22 of 34

INVESTIGATIONS

PT: 16 sec

INR: 1.11

APTT: 32 sec

BT: 2 min 00 sec

CT: 4 min 30 sec

S.Amylase: 59 IU/L

S.Lipase: 26 IU/L

Serology: Negative

MP strip: Negative

Covid-19 RTPCR: Negative

23 of 34

INVESTIGATIONS

USG ABDOMEN:

  • Altered echotexture of liver
  • GB wall edema
  • Mild ascites

2D ECHO:

  • EF: 58%
  • No RWMA , No AS/MS
  • Trivial AR+/TR+
  • Sclerotic AV , No PAH , No PE / LV clot
  • Diastolic dysfunction +
  • IVC size: 1.1 cms

24 of 34

TREATMENT

  • IVF NS,RL @150ML/HR
  • RT FEEDS 100ML FREE WATER - 1 HOURLY, 200ML MILK WITH PROTEIN.

POWDER – 2ND HOURLY

  • INJ. AUGUMENTIN 1.2GM IV/BD
  • INJ. PANTOP 40MG IV/OD
  • INJ. HYDROCORT 100MG IV BD
  • INJ. THIAMINE 200MG IN 100ML NS IV/BD
  • NEBULIZATION WITH MUCOMIST, BUDECORT 6TH HRLY
  • SYRUP. LACTUOSE 15ML/BD
  • 1 UNIT SDP TRANSFUSION
  • CHEST PHYSIOTHERAPY
  • ET & ORAL SUCTION 2ND HOURLY
  • BP/PR/ TEMP MONITORING 2ND HOURLY

​

25 of 34

INVESTIGATIONS

HEMOGRAM (18/08/21):

  • HB - 9.2 GM/DL
  • TOTAL COUNT - 12300 CELLS/CUMM
  • NEUTROPHILS - 82% , LYMPHOCYTES - 10% , EOSINOPHILS - 01% , MONOCYTES - 07% , BASOPHILS - 00%
  • PCV - 25.6 VOL%
  • MCV - 88.3 FL
  • MCH - 31.7 PG
  • MCHC - 35.9%
  • RDW-CV - 18.2%
  • RDW-SD - 58.8 FL
  • RBC COUNT - 2.90 MILLIONS/ CUMM
  • PLATELET COUNT - 1.05 LAKHS/CUMM
  • SMEAR: NORMOCYTIC NORMOCHROMIC BLOOD PICTURE WITH NEYTROPHILIC LEUCOCYTOSIS AND MILD THROMBOCYTOPENIA

26 of 34

INVESTIGATIONS

RFT (18/08/21):

  •  UREA 100 mg/dl
  •  CREATININE 2.5 mg/dl
  •  URIC ACID 8.4 mg/dl
  •  CALCIUM 10.0 mg/dl
  •  PHOSPHOROUS 5.3 mg/dl
  •  SODIUM 142 mEq/L
  •  POTASSIUM 3.0 mEq/L
  •  CHLORIDE 102 mEq/L

​

27 of 34

INVESTIGATIONS

ABG (18/08/21):

  •  PH 7.20
  •  PCO2 38.3
  •  PO2 83.8
  •  HCO3 14.4
  •  St.HCO3 14.6
  •  BEB -12.5
  •  BEecf -12.0
  •  TCO2 31.1
  •  O2 Sat 90.9
  •  O2 Count 14.1

28 of 34

INVESTIGATIONS

ABG (18/08/21):

  •  PH 7.13
  •  PCO2 54.6
  •  PO2 60.6
  •  HCO3 17.7
  •  St.HCO3 15.4
  •  BEB -11.3
  •  BEecf -9.8
  •  TCO2 38.4
  •  O2 Sat 82.1
  •  O2 Count 14.4

​

  • In suspicion of tube block patient was extubated & reintubated with ET 7.5

29 of 34

TREATMENT

  • AIR BED
  • IVF NS,RL @150ML/HR
  • RT FEEDS 100ML FREE WATER - 1 HOURLY, 200ML MILK WITH PROTEIN.

POWDER – 2ND HOURLY

  • INJ. AUGUMENTIN 1.2GM IV/BD
  • INJ. PANTOP 40MG IV/OD
  • INJ. HYDROCORT 100MG IV BD
  • INJ. THIAMINE 200MG IN 100ML NS IV/BD
  • NEBULIZATION WITH MUCOMIST, BUDECORT 6TH HRLY
  • SYRUP. LACTUOSE 15ML/BD
  • SOAP WATER ENEMA
  • CHEST PHYSIOTHERAPY
  • ET & ORAL SUCTION 2ND HOURLY
  • BP/PR/ TEMP MONITORING 2ND HOURLY

​

30 of 34

INVESTIGATIONS

ABG (19/08/21):

  •  PH 6.89
  •  PCO2 56.8
  •  PO2 37.4
  •  HCO3 10.3
  •  St.HCO3 8.1
  •  BEB -21.2
  •  BEecf -20.2
  •  TCO2 25.7
  •  O2 Sat 35.7
  •  O2 Count 3.7

31 of 34

DEATH SUMMARY

  • 70 Year old male patient was brought to casualty in an unconscious state with h/o fever since 4 days , pain abdomen since 3 days f/b unresponsiveness since 1 day
  • Outside reports show DENGUE NS1 POSITIVE
  • On arrival in casualty his GCS: E1V1M1 , BP: 70/40 mmhg , SpO2: 78% on RA & GRBS: 34 mg/dl
  • Immediate resuscitation with IV Fluids , 25% Dextrose & O2 supplementation was done and patient was intubated in view of poor GCS (3/15) , falling saturation and connected to mechanical ventilator
  • Post resuscitation GCS: E2VTM4 , BP: 100/60 mmhg , SpO2: 99% & GRBS: 342 mg/dl

​

​

32 of 34

DEATH SUMMARY

  • All further Investigations were done which showed severe thrombocytopenia , AKI & Hepatitis (viral/alcoholic) and treated conservatively.
  • On 19/08/2021 at 06:50 am, patient suddenly became unresponsive with no recordable BP & pulse.
  • CPR was initiated & continued for 6 cycle.
  • Despite of the resuscitative measures patient couldn’t be revived &declared dead on 19/08/2021 at 07:22am

33 of 34

DEATH SUMMARY

IMMEDIATE CAUSE OF DEATH:

  • DENGUE SHOCK SYNDROME
  • SEVERE METABOLIC+RESPIRATORY ACIDOSIS

ANTECEDENT CAUSE OF DEATH:

  • HYPOXIC ISCHEMIC ENCEPHALOPATHY
  • ALCOHOLIC/VIRAL HEPATITS
  • ACUTE KIDNEY INJURY. 

​

34 of 34

THANK YOU