dr. unadkat (m&m)

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  • 8/11/2019 Dr. Unadkat (M&M)

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    2ndApril 2014

    Dr. Megha Unadkat

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    CHIEF COMPLAINT & HPI

    Fever

    3/7 Sudden onset

    Low-high grade fevers associated with mild cough

    Hx of poor feeding and loss of appetite

    No hx of wheezing/DIB No hx of vomiting/diarrhea

    No hx of convulsions

    No hx of ear/nasal discharge

    No hx of difficulty in micturition

    Taken to a local hospital where baby was given injectionDiclofenac and Diazepam PR

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    BIRTH HISTORY

    Patient delivered via emergency C/S on the 21/3/2013 at AKH

    due to severe IUGR and breech presentation with cord around

    the neck at GA of 36 weeks.

    Birth Weight = 1.6 Kg

    Baby had Apgar score of 7- 8

    Given IVFstayed for 3 days

    Exclusively breastfed for 4/12

    Maternal factors Reduced fetal movements

    PIH noted in last 2 ANC visitsTotal 6 visits

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    ON EXAMINATION

    AVPU , afebrile (37C), pale +, not jaundiced ,

    cold extremities

    RR- 77-83 b/min (tachpynoea)

    HR- 189 bpm (tachycardia)

    SPo283% on RA , 95% on 5L of O2

    (babymask) Weight - 5.5 Kgs

    Dehydration: moderate

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    SYSTEMIC EXAMINATION

    RS

    LCWI, Intercostal recessions

    No area of tenderness

    Bilaterally symmetrical expansion

    Bilateral coarse crackles, Right >>Left side

    CVS

    Regular, strong peripheral pulses.

    Apex beat at 4th ICS

    S1 and S2- normal, no murmurs

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    P/A

    Normal contour, soft, non tender

    Liver 2 cm enlarged below RSCM Kidney and spleen not palpable

    Tympanic percussion and normal bowel

    sounds heard.

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    PROVISIONAL DIAGNOSIS

    Severe Pneumonia with septic shock

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    INITIAL LABS

    CBC

    Malaria (dual) negative

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    WBC 7.1 K/uL

    HB 8.6 g/dl

    Platelets 85 K/uL (thrombocytopenia)

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    Electrolytes

    Creatinine: 69.63 umol/L (59-104)

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    Sodium 128.12 mmol/L 136-145

    Potassium 5.26 mmol/L 3.3-5.5

    Chloride 103.45 mmol/L 98-104

    HCO3- 7.24 mmol/L 18-28

    Anion Gap 17.43 mmol/L 6-20

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    CXR

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    MANAGEMENT (02:30 HRS - CASUALTY)

    Plan:

    NS bolus 110 mls IO

    DNS maintenance IO

    IM ceftriaxone 500mg STAT/OD (75mg/kg)

    Salbutamol Nebs 2.5 mg Q3H

    Oxygen 2L/min

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    IN THE WARD09:30 AM

    o/e: Still drowsy, dyspneic, pale, cold extremities,

    faint peripheral pulses, capillary refill > 3 seconds ,

    on O2 via nasal prongs, acidotic breathing, no

    peripheral line present RS: crackles R>>L

    CVS: tachycardic

    P/A: soft, liver enlarged 6-7cm BRSCM

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    ImpressionSevere Pneumonia (?Aspiration) with

    acidosis

    Anemia in heart failure

    Septic shock

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    Plan: To cannulate (successful) To do blood grouping/cross matching

    Transfuse whole blood 120mls Lasix 6mg before

    transfusion

    NS bolus 120 mls (given twice)

    IV clindamycin 60mg STAT/Q6

    Discuss with ICU for transfer ( no space in ICU

    until a transfer out)

    Mother was informed

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    IN THE WARD10:55 AM

    Baby went into Cardiopulmonary arrest

    Bag & Mask ventilation with chest compressions

    were initiated

    IV adrenaline was started

    Consultant + ICU team informed

    Intubation was done with ETT and suctioningdone

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    20 cycles of adrenaline given with no response

    (HR still 2 hrs

    Family informed

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    CAUSE OF DEATH ???

    Severe Pneumonia with acidosis leading to

    Respiratory failure

    Septicemia

    Anemia in heart failure

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