Mortality Conference

1. Case Presentation
Arsalan Masoud
PGR, North Medical Ward
Mayo Hospital, Lahore

2. Bio Data
Patient’s Name Naseeba Bibi
Age / Sex 60 year old Female
Reg # 1742/15
Address Okara
DOA 28-08-2015
MOA Emergency
DOD 01-09-2015

3. Emergency Assessment and Management
Chief Complaints:
▪ Fever for 1 day
▪Altered state of consciousness for 1 day
Relevant Examination:
▪BP: 170/80mmHg
▪BSL: ?
▪GCS 4/15
▪Right Plantar Reflex Upgoing
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4. Investigations Advised:
▪Baselines
▪CT Scan Brain Plain
▪ECG
▪USG Abdomen
Treatment Given:
▪Inj C-trox 1g IV x stat
▪Inj Zantac 50mg IV x stat
▪Inj Marzine 10mg IV x stat
▪PROVISIONAL DIAGNOSIS Ischemic CVA
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5. Presenting Complaints
▪ Fever 3-4 Days
▪ Fits 3 Days
▪ ASOC 3 Days

6. History of Presenting Illness
Patient was in usual state of health 3 days back when she
developed fever which was sudden in onset, high grade,
continuous, without any specific pattern or any diurnal
variation and wasn’t relieved even on taking medications.
Fever was associated with 2-3 episodes of tonic- clonic
fits lasting for 1 minute each and relieved by Inj.
Diazepam.This was accompanied with frothing from
mouth.There was no h/o Up-rolling of eyes, no h/o
urinary or fecal incontinence.The fits were followed by
ASOC, which was sudden and progressive in nature.
There was no h/o fits prior to this.

7. No h/o cough or sputum, No h/o of Sore
throat, No h/o chest pain, No h/o
Palpitations, No h/o SOB, No h/o Orthopnea
or PND, No h/o Nausea orVomiting, No h/o
Diarrhea or Constipation, No h/o Burning
Micturition, No h/o of Oliguria, Polyuria or
Hematuria.
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8. Past History:
 Known Asthmatic 30 years with poor compliance to
medication.
Known Hypertensive 10 years with poor compliance to
medication.
No History of DM, IHD,T.B

9. Family History:
Non Significant
Personal History:
Non Smoker and Non Addict
Drug History:
Off and on medications for
hypertension & Asthma

10. Physical Examination:
A middle aged, obese, ill looking female patient lying unconscious in
bed with vitals of
B.P 150/90 mmHg
Pulse 80/Min
Temp 105º F
R.R 24/Min
O2 Sat 94 %

11. ▪ Pallor - ve
▪ Clubbing - ve
▪ Leukonychia - ve
▪ Jaundice - ve
▪ JVP Not Raised
▪ Cyanosis - ve
▪ Pedal Edema - ve
▪ Lymphadenopathy - ve
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12. Systemic Examination:
Nervous System:
GCS E1V1M2 4/15
Plantars B/L Mute
SOMI - ve
Pupils B/ L Normal, Reactive to light
Tone B/L Normal of both upper and lower limbs
Power and sensory system couldn’t be assessed patient being
unconscious

13. Gastro-intestinal System:
Soft, protuberant abdomen with no viscerae palpable on examination.
Bowel sounds 3/min.
Cardiovascular System:
Apex beat in the 5th
intercostal space just medial to the midclavicular
line.
S1 + S2 + 0
Respiratory System:
Resonant, comparable percussion note B/L
NVB + No added sounds on auscultation
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14. Investigations:
CBC (29-08-2015)
▪WBC: 9.4 Thousands/microL
▪Hb: 11.0 g/dL
▪HCT: 29.4 %
▪MCV: 91 fL
▪Plt Count: 187 Thousands/microL
▪Neutro: 67.1 %
▪Lympho: 27.4 %
▪Mono: 4.5 %
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15. 29-08-2015
LFTS
▪ S/Bilirubin 1.0 mg/dL
▪ S/AST 71 U/L
▪ S/Alk. Phosphatase 242 U/L
▪ S/Total Proteins 6.5 g/dL
▪ S/Albumin 3.7 g/dL
RFTs
▪ S/Creatinine 0.8 mg/dL
▪ Blood Urea 33 mg/dL
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16. 29-08-2015
Serum Electrolytes
▪ Sodium 141 mmol/L
▪ Potassium 4.1 mmol/L
▪ S/Calcium 7.6 mg/dL
▪ S/PO4 3.7 mg/dL
▪ S/Choride 98.0 mg/dL
ABGs
▪ pH 7.398
▪ pCO2 43.6 mmHg
▪ pO2 83.4 mmHg
▪ HCO3 26.3 mol/L
▪ Base Excess -1.4
▪ O2 Sat 88.9 %
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17. 30-08-2015
▪ CSF Analysis
▪ Volume: 3 ml
▪ Appearance: ClearWatery
▪ Xanthochromia: Negative
▪ Glucose: 83 mg/dL (BSL at that time 164 mg/dL)
▪ Protein: 68 mg/dL
▪ LDH: 40 U/L
▪ RBCs: 283/cmm
▪ WBCs: 63/cmm
▪ Neutrophils: 05%
▪ Lymphocytes: 95%
▪ No Atypical or Malignant cells were seen.Coagulation Studies
PT 16 sec (control 14)
aPTT 39 sec (control 35)
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18. ▪ CT Scan Brain Plain:
▪ Two CT scans were done.
▪ One of which was done on 28-08-2015 and the other done on 29-08-
2015. Study of both was unremarkable.
▪ USG Abdomen:
▪ Fatty liver with normal liver size, normal spleen and kidneys.
▪ Differential Diagnoses
▪ Ischemic CVA
▪ Meningoencephalitis
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19. Treatment Prescribed
▪ 28-08-2015
▪ Inj Omeprazole 40mg IV x OD
▪ Tab Motilium 1 x PO xTDS
▪ Tab Loprin 150mg 1 x PO x OD
▪ Tab Atorva 20 mg 1 x PO x H.S
▪ Syp Duphalac 2TSF xTDS
▪ Inf Ringer’s Lactate 1000mL IV
x BD
▪ Tab Panadol 2 x PO x SOS
▪ 29-08-2015
▪ Inj Diazepam IV x SOS
▪ Inj C-trox 1g x IV x BD
▪ Added to the previous regimen
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20. ▪ 30-08-2015
▪ Inj C-trox 2g IV x BD
▪ Inj Aclova 750mg IV xTDS
▪ Inf N/S 1000ml x IV x OD
▪ Inf R/L 1000ml x IV x OD
▪ Inj Artem 160mg IM x stat
Then 80mg x IM x OD
Inj Mannitol 100ml x IV xTDS
Inj Diazepam x IV x SOS
Tab Disprin 150mg 1 x PO x OD
▪ 31-08-2015
▪ InjVancomycin 1g x IV x BD
Added to the previous regimen
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21. Chronology of Morning DPNs
▪ 29/08/2015
▪ Diagnosis: Ischemic CVA
▪ Pulse: 90/min
▪ Temp 106 ºF
▪ BP: 140/100 mmHg
▪ R/R: 18/min
▪ Chest: Clear
▪ GCS 4/15
▪ Assessment: static
▪ Plan: CST
▪ 30-08-2015
▪ Diagnosis: Ischemic CVA
▪ A/C: Fits
▪ Pt Critically ill
▪ GCS: 5/15
▪ BP: 160/100 mmHg
▪ Pulse: 85/min
▪ Temp: 106ºF
▪ Plan: ECG, ABGs, Infusion
Diazepam + Inj Epival + CST
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22. ▪ 31-08-2015
▪ Diagnosis Ischemic
CVA/Meningo-encephalitis
▪ Pulse 98/min
▪ BP 150/90 mmHg
▪ Temp 104ºF
▪ Respiratory Rate 18/min
▪ Resp System NVB + B/L coarse
crepts+ conducting sounds
▪ GCS 3/15
▪ SOMI –ve
▪ B/L Plantars Mute
▪ Assessment Critical
▪ Plan: Baselines, MP Slide,
Blood Cultures, LP results
awaited, Lactodil Enema,
HBsAg + Anti HCV
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23. WHAT WAS WRONG IN THE
MANAGEMENT?
Patient was having high grade fever before she had fits and went in an
altered state of consciousness. Association of fever is important.
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29. VIRAL ENCEPHALITIS
▪ In case of suspicion of viral
encephalitis Inj Acyclovir 10-
15mg/kg every 8 hours for 14-
21 days.
▪ Role of Mannitol?
▪ Inj Mannitol 1.5-2Gm/kg iv x
TDS for two days then start
tapering.
▪ Role of
Dexamethasone?
▪ Inj Dexamethasone 2 c.c x IV x
TDS
▪ It helps decrease Cerebral
Edema in any case of
Meningoencephalitis.
▪ It has no role in CVAs.
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30. CEREBRAL MALARIA
▪ When to add an Anti Malarial in the Empirical
Treatment?
▪ Hints pointing toward cerebral malaria
▪ In the absence of clear cut signs of meningism.
▪ Seizures both focal and generalized
▪ High grade Intermittent fever
▪ An abrupt lowering in Hb
▪ Multiple episodes of Hypoglycemia
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31. Anti Malarials in Cerebral Malaria
▪ WHO recommends the use of injectables whenever cerebral malaria
is suspected. (Plasmodium falciparum is attributed to Cerebral
Malaria in most cases)
▪ WHO recommends Inj Artesunate 2.4 mg/kg IV/IM at 0, 12 hours, 24
hours,THEN qDay for 7 days or until patient can take oral drug
▪ Alternatively Inj Quinine dihydrochloride in a loading dose of
20mg/kg and then 10mg/kg each in three doses daily.This is diluted
in 500ml of 5% D/W
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32. SUMMARY OF EMPIRICAL TREATMENT FOR
CEREBRAL INFECTIONS
▪ Inj Ceftriaxone 2g x IV x BD
▪ InjVancomycin 1g x IV x BD
▪ Inj Acyclovir 750mg x IV xTDS
▪ Inj Dexa 2 c.c IV xTDS
▪ Inj Mannitol 100-150 c.c IV xTDS(acc to edema on CT scan)
▪ Inj Artesunate 2.4mg/kg at 0, 12, 24 hrs and then OD until patient
can take oral dosage or for 7 days.
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33. THANK YOU!
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