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1. CONTINUOUS QUALITY
IMPROVEMENT
DURATION OF STAY: 11 hours
Presentation by: Dr. Tejasri .K
First year Post Graduate
Department of General Medicine

2. Chief Complaints
A 48 year old male was brought to the ER with
complaints of:
• Fever since 5days
• Absence of urine output for 1 day
• Shortness of breath since 1day
• Palpitations since 2hrs

3. Presentation to hospital
Patient was apparently normal 3 days back when patient
developed
• Fever since 5days,last episode 1day ago,high grade ,
intermittent associated with chills,myalgia and
athralgia,and fatigue since 5days,relieved with
medication.
• Complete absence of urine output for 1day
• Shortness of breath grade-4 since 1day which is sudden
in onset progressive associated with orthopnea , no pnd,
• Palpitations since 2 hrs sudden in onset ,aggrevated on
work, not progressive , not associated with chestpain or
sweating

4. • No history of headache, neck pain, burning
micturition, vomiting,loose stools, chest pain, cough
• No burning and tingling sensations of arms and legs

5. CBP
Hb 12.7
TLC 5500
DC 65/31/3/1/0
PCV 39.3
Platelet count 15000
MCV 110
MCH 36.6
MCHC 33.9
PERIPHERAL
SMEAR
Normocytic
normochromic
creatinine 2.4
urea 67
Na 141
K+ 3.3
Cl- 107
Amylas
e
32
Lipase 32
NT
ProBNP
20776.35
trop i positive
Patient visited outside hospital 1day ago where labs showed:

6. LFT
Total bilirubin 3.7
Direct
bilirubin
2.1
Indirect
bilirubin
1.6
ALP 167
SGOT 59
SGPT 30
Total proteins 7.0
Serum
albumin
4.2

7. • USG showed hepatomegaly with altered increased
echotexture –Alcohol liver disease ,cholelithiasis with sludge
in gb lumen.
• Foleys catheterisation done and got treated with ionotropes,
antibiotics and other supportive medication for 1 day ,one
sdp transfusion was also done. Patient was referred to
PSIMS & RF for further evaluation and management.
• Patient diagnosed as viral fever with thrombocytopenia
with heart failure ?cause

8. PAST HISTORY
• Not a k/c/o DM,HTN , CKD ,CAD, CLD, epilepsy,
thyroid disorders, BA, COPD
PERSONAL HISTORY
• known smoker since 5 years -10 cigerettes per day-
2.5pack years
Occasional alcoholic since 25 yrs drinks 180ml/day .
• No history of drug/ food allergies
FAMILY HISTORY- nil

9. Initial Evaluation
• Patient was conscious and oriented to time, place and
person at the time of presentation.
• Moderately built, moderately nourished
• No pallor, icterus,cyanosis, clubbing, lymphadenopathy,
edema
• Petechia present on soft palate
• Gum bleed present

10. • Vitals at presentation:
BP: 100/60mmhg on 12.5mic/hr nor adrenaline, 3.8meq/hr
dobutamine
PR: 100/min
RR: 34/min
Temp: 98.7F
spO2: 89% on 10l O2
GRBS: 84 mg/ dL
Hess test-positive

11. Systemic Examination
RS:
• Trachea in midline
• No scars sinuses engorged veins
• Bilateral symmetrical chest movement
• No bony tenderness present
• Bilateral air entry +
• Bilateral coarse crepts with wheeze present in isa ssa iaa

12. GIT:
• Abdomen is distended
• Umbilicus in midline and inverted
• All quadrants move equally with respiration
• On palpation
no organomegaly
soft tender in all quadrants
• On auscultation bowel sound heard

13. CVS:
• No visible precordial bulge present
• Apex beat felt in 5 th ICS ½ inch medial to midclavicular line
• On auscultation : S1 S2 heard
• S3 present
• No murmurs
CNS:
• GCS = E4V5M6
• PUPILS – BL NSRL
• No signs of meningeal irritation
• B/l plantars - flexor

14. ABG
At 10 litre O2
pH 7.429
pO2 73.2
pCO2 24.1
HCO3 15.7
Lactate 5.9
Interpretation Respiratory alkalosis with
lactic acidosis

15. ECG

16. CARDIOLOGY OPINION
2D echo:
• mild LV function EF -45 %
• Global hypokinesia
• Grade 1 LV Diastolic dysfunction
• no MR ,mild TR,PAH
• RVSP- 38 mmhg
• No PE , clot , vegetations
• IVC – mid dilated and collapsing <50%
ADVICE
• Antiplatelets and anticoagulants were not added due to
thrombocytopenia
• tab ATORVAS 20 mg p/o 24th
hrly

17. Chest X-ray

18. Provisional Diagnosis
• ?Heart failure
• ?viral Fever with Severe thrombocytopenia

19. CBP 20/8 21/8
Hb 11.1 9.5
TLC 3800 4000
DC 94/4/0/1/0 88/8/2/2/0
PCV 36.3 28.6
Platelet
count
15000 8000
MCV 110 110
MCH 36.6 37.4
MCHC 33.9 33.9
PERIPHER
AL SMEAR
Normocytic
normochromi
c anemia
and
creatinin
e
1.4 1.4
urea 77 82
Na 142 138
K+ 4.2 3.9
Cl- 107 105
Amylas
e
32
Lipase 10.44
NT
ProBNP
22265.3
trop i 10,323

20. LFT
Total bilirubin 2.0
Direct
bilirubin
1.2
Indirect
bilirubin
0.8
ALP 63
SGOT 102
SGPT 36
Total proteins 4.8
Serum
albumin
2.6
Esr 190
Crp 524
PT 38.2
INR 2.8

22. USG Abdomen and pelvis
• hepatomegaly with grade 2 fatty liver changes

23. Treatment History
In ER
• Case was shifted to MICU and pt was kept on BIPaP i/v/o tachypnoea
In ICU:
• i/v fluids 1NS ,1RL @75 ml/hr
• Inj. noradrenaline infusion at 12.5mic/hr
• Inj. dobutamine infusion at 3.6meq/ hr
• inj meropenem 1gm iv 12th hrly
• Inj. Pantop 40 mg IV 24th
hrly
• inj . Thiamine 500mg stat in 100 ml NS followed by 100 mg in 100ml NS 8th
hrly
• inj zofer 4 mg iv 12th
hrly
• tab atorvas 20 mg po 24th
hrly
• TAB Chlordiazepoxide 25 mg po 8th
hrly
• Input/ output charting
• Vitals monitoring

24. Course in the hospital
• Patient was shifted to ICU and was put on BiPap initially
due to tachypnoea , as there is persistent increase in work
of breathing patient and pt became drowsy was sedated
and intubated on 21th
August 2025 at 5:00AM.
• mode -vc
• tv-420 ml
• fio2-80 %
• rr-14/ min
• i:e -1:2
• peep- 5 cm h20

25. • Vitals:
Pre-intubation
BP: 100/60mmhg on 12.5mic/hr
nor adrenaline,3.6meq/hr dobutamine
PR: 130/min
RR: 50/min
spO2: 95% on niv 75%
Post intubation
BP: 120/60mmhg on 12.5mic/hr
nor adrenaline, 3.6meq/hr dobutamine
PR: 130/min
RR: 20/min
spO2: 98% on 80% fio2

27. VBG
At 90% FiO2
pH 7.239
pO2 55.3
pCO2 44.9
HCO3 16.7
Lactate 6.7
Interpretation Metabolic acidosis with
lactic acidosis

28. • IV FLUID 25%D stat
• inj doxycycline 100 mg iv 12 th hrly
• ryles feed 2nd hrly
• Rest continued same trt
VITALS:
BP-90/60 mmhg on
noradrenaline 12.5mic/
hr
3.6 ml/ hr dobutamine
PR- 150 bpm
RR-20 cpm
TEMP- 1030
F
SPO2- 70 %on 90%FiO2
I/O - 1400/215 ml
GRBS -30 mg/dl
DAY2

29. • While on mechanical ventilation patient suddenly got desaturated
with non palpable carotids at 10.04am on 21th
August, 2025. High
quality CPR was initiated according to ACLS guidelines.
• Despite adequate resuscitative efforts patient could not be revived
and ECG showed flatline at 10.39am on 21th
august 2025.

30. Final Diagnosis
Viral hemorragic fever
With thrombocytopenia
?fulminant myocarditis

31. Thank you