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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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