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General Data

General Data. C.D. Age/Sex/Status: 81/F/Widow Address: San Miguel, Manila Date of birth: May 19, 1929 Place of birth: Manila Occupation: Unemployed Religion: Roman Catholic. Chief Complaint Difficulty of breathing. History of the Present Illness. Past Medical History.

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General Data

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  1. General Data • C.D. • Age/Sex/Status: 81/F/Widow • Address: San Miguel, Manila • Date of birth: May 19, 1929 • Place of birth: Manila • Occupation: Unemployed • Religion: Roman Catholic

  2. Chief ComplaintDifficulty of breathing

  3. History of the Present Illness

  4. Past Medical History • Head trauma (May 2009) – UST Neurosurgery (CT Scan unremarkable) • (-) HPN, DM, CA • (-) Thyroid disorders • (-) Asthma, Allergies, PTb • (-) Previous blood transfusion

  5. Personal and Social History • Mixed Diet • Nonsmoker • Non-alcoholic beverage drinker • No illicit drug use

  6. Family History • Gallstone – sister • HPN – brother • (-) DM • (-) CA • (-) Asthma, PTB

  7. Review of Systems • General: no weight loss • Skin: no rashes, no sores, no itching • Head: no headache, no dizziness • Eyes: no blurring of vision, no redness • Ear: no ear pain, no discharge • Nose: no epistaxis • Throat: no sore throat • Neck: no nape pain, no stiffness • Cardiovascular: no chest pain, no easy fatigability, no PND • Gastrointestinal: no diarrhea, no constipation, no vomiting • Genitourinary: no hematuria, no dysuria • Musculoskeletal: no joint pain, no swelling • Endocrine: no heat and cold intolerance, no excessive sweating, no polyphagia • Hematopoetic: no easy bruisability

  8. Physical Examination upon Admission • Lethargic, incoherent, stretcher-borne, hyposthenic, in cardiorespiratory distress • BP 140/80 PR 105bpm RR 26 T 37.8ºC • Weight : 45kg Height : 4’10 ‘’ BMI : 20 • Warm, dry skin, no active dermatoses, no rashes • Incisional scar on occipital área, no hair thinning • Pink palpebral conjunctivae, anicteric sclerae, pupils 1-2mm ERTL • No nasoaural discharge, no alar flaring • Moist buccal mucosa, (+) food particles in mouth, non-hyperemic posterior pharyngeal wall • Rigid neck, no palpable lymphadenopathies, thyroid not enlarged • Symmetrical chest expansion, (+) subcostal and intercostal retractions, (+) crackles on both lung fields, vocal fremiti and tactile fremiti cannot be assessed • Adynamic precordium, AB 5th LICs MCL, S1>S2 at the apex, S2>S1 at the base, no murmurs, lifts, thrills, heaves • Flabby abdomen, soft, non tender, no masses • Pulses were full and equal, no cyanosis, no edema

  9. Neurological Examination • Lethargic,(+) spontaneous respiration, refuses to open eyes, no verbal output (intubated), localizes to pain, GCS 9 (E3V1M5) • CN: Pupils 1-2 mm ERTL, no visual threat, (+) corneal reflex OU, brisk • Motor: no preferential weakness, can maintain both lower extremities against gravity • DTRs ++ on all extremities • (+) Bilateral Babinski, more consistent on the left • Meningeal signs: (-) Nuchal rigidity, (-) Kernig’s • Rigidity on all directions of neck movement

  10. CAD, NSTEMI 3/22/10

  11. Course in the Wards • ADMISSION: • ECG: sinus rhythm and diffuse ischemia. • TroponinI : elevated • Medications: • Trimetazidine35mg/tab 1 tab BID, • Clopidogrel75mg/tab 1 tab OD, • ISMN 30mg/tab 1 tab OD, • Atorvastatin80mg/tab 1 tab ODHS, • Metoprolol50mg/tab 1 tab BID, and • Fondaparinux2.5mg/SC OD were then started • Repeat ECG: showed sinus rhythm and ST-T wave changes due to ischemia or hypokalemia

  12. Course in the Wards • On the 14th HD: • 2d echo with Doppler: normal left ventricle with interventricularseptal hypertrophy with good wall motion and contractility and normal resting systolic function, calcified mitral valve annulus and mild aortic regurgitation, mild mitral regurgitation and mild tricuspid regurgitation with EF of 75%

  13. Course in the Wards • On the 19th HD • patient’s BP was 200/100, • Medications: • Nicardipine drip started at 10mg + 90cc PNSS to un at 3cc/hr, titrated by 22cc/hr for systolic BP control to 110-130mmHg

  14. Course in the Wards • On the 41st HD • ECG: showed normal sinus rhythm with marked sinus arrythmia, Premature ventricular complex in couplet, occassional, premature atrial complexes. So • Medication: • Clopidogrel 75mg/tab 1 tab OD continued

  15. Course in the Wards • On the 46th HD, • patient developed atrial fibrillation • ECG: normal sinus rhythm with isolated premature atrial complex in V6. • Medication: • Amiodarone 300 mg/IV was given and was maintained at 200 mg/tab OD • Carvedilol 6.25 mg/tab 1 tab OD

  16. Course in the Wards • On the 51st HD • Increasing trend in BP (140/90 to 160/100) • Medication: • Losartan 50 mg/tab OD • On the 72nd HD, • Medication: • Trimetazidine 75 mg/tab 1tab BID • Omacor 1 tab OD were started

  17. Course in the Wards • On the 101st HD, • Trimetazidine, Omacor, and Duxaril was discontinued • On the 102nd HD, • amlodipine was put to hold, because patient has stable blood pressure(100-120/70-80) for the past month. • On the 103rd HD, • clopidogrel 75 mg/tab 1 tab OD was resumed.

  18. CAD, NSTEMI Outcome: Unresolved

  19. Decreased sensorium 3/22/10

  20. Course in the Wards • Admission • patient was noted to be lethargic, GCS9 (E3V1M5) • referred to Neurology • Assessment: Metabolic encephalopathy probably secondary to • 1. Hypoxia, • 2.Systemic infection; r/o Old bilateral lacunarinfarction. • Cranial MRI was suggested to document possible previous infarction. • LMWH and anti-platelet were continued. • Citicholine 1g/IV q12 was started. • Outcome: • There was noticeable improvement in patient’s sensorium (GCS11 E4V1M6)

  21. Course in the Wards • On 6th HD, • patient had occasional spontaneous eye opening, followed some commands with pupils 2mm ERTL, and can move all extremities equally. • Citicholine 500mg/cap BID was continued

  22. Decreased sensorium Outcome: Resolved

  23. Problem: Anemia 3/22/10

  24. Course in the Wards • Admission: • patient had pale palpebralconjunctivae • CBC: slightly low hemoglobin (Hgb 119) • 3rd HD • Repeat CBC:Hgb 86. • Blood transfusion with 2 ’u’ PRBC was done with strict congestion precaution. • On the 4th hospital day • Repeat CBC: normal hemoglobin

  25. Course in the Wards • On the 11th HD, • repeat CBC showed Hgb of 93, patient was again transfused 1 ‘u’ PRBC and repeat CBC showed Hgb of 120. • On the 14th HD, • repeat CBC showed Hgb of 98, patient was transfused with 1 ‘u’ PRBC and repeat CBC showed Hgb of 106. • On the 40th and 44th HD, • repeat CBC showed a decreasing trend for Hgb (116 to 101).

  26. Course in the Wards • On the 54th HD, • CBC: Hgb=105 with normal platelet and WBC • On the 93rd HD, • CBC: hemoglobin of 80 • One unit of packed RBC divided to two aliquots was transfused for over twelve hours.

  27. Problem: Anemia Outcome: Resolved

  28. Aspiration Pneumonia 3/22/10

  29. Course in the Wards • Upon admission • Respiratory distress with RR of 28, febrile at 37.8C, with bibasilar crackles • CXR: ill-defined infiltrates over both lung bases, more on the right side, which may represent pneumonic process • Patient was hooked to mechanical ventilator under AC mode, TV 350, FiO2 100%, BUR 18, P/F 60, • combiventnebulization + 2cc Ambroxol q8 were also given and Ertapenem 1g/IV OD and N-acetylcysteine 600mg/tab 1 tab OD were started • Patient was maintained on moderate to high back rest with strict aspiration precaution • Azithromycin500mg/tab 1 tab OD was added to previous medications • Decrease in bibasilar crackles was observed but patient still had febrile episodes

  30. Course in the Wards • On the 4th HD • Persistence of febrile episodes and patient developed crackles and rhonchi on both lung fields • Ertapenem was shifted to Piperacillin-Tazobactam 4.5g/IV q8 and paracetamol 500mg/tab q4 PRN for T  38.0C was given • CXR: showed magnified cardiac size, sclerotic aortic arch, progression of pneumonic infiltrates in both lungs, bilateral pleural effusion, and osteopenia of visualized osseous structures. • On the 7th HD • Patient was still febrile and with bilateral crackles • CXR: minimal resolution of the interstitial alveolar infiltrates in both lung with slight resolution of pleural effusion bilaterally. • On the 8th HD • Persistence of febrile episodes, with crackles bilaterally, was referred to Infectious Disease service, and was started on Amikacin 700mg/IV via infusion for 2 hours, once a day for 5 days. • ET aspirate was submitted for culture and sensitivity and grams stain which revealed no microorganims seen with PMN leukocytes of 4 plus.

  31. Course in the Wards • On 11th HD • ET aspirate C & S result revealed Klebsiellapneumoniae, hence Piperacillin-Tazobactam was shifted back to Imipenem when afebrile. • On the 15th HD • Patient underwent tracheostomy. • Post-op, patient tolerated the procedure well, she was afebrile with decreased crackles on both lung fields • Repeat CBC showed normal WBC count. Imipenem was then shifted down to ciprofloxacin 500mg/tab, 1 tab BID and co-amoxyclav 625mg/tab, 1 tab BID both to be taken for 14 days. • On the on the 18th HD • CXR: progression of pleural effusion on the right and with hazy opacities still on right lung upper lobe. • ET aspirate GS and CS were also requested. Anitbiotics and duaventnebulation q8 were continued.

  32. Course in the Wards • On the 20th HD • Patient experienced difficulty in breathing and ABG was requested and showed partially compensated respiratory acidosis, mechanical ventilator set-up was then adjusted accordingly and duaventnebulization was increased to q6. • On the 25th HD • ABG: fully compensated respiratory acidosis and pneumothorax in the right hemithorax, regression of pulmonary edema, with no significant change in pleural effusion, respectively. • On the 28th HD • CXR: when compared to the one done 4/16/10 showed progressive haziness over the right lungfield, as well as the left lower lung area, there is slight reexpansion of the right upper lung area. • Antibiotics were still continued and congestion was entertained so intravenous fluids was discontinued and Furosemide 20 mg/IV was given. • On the 30th HD • Her antibiotics, which she took for 14 days were discontinued. • On the 31st HD • CXR revealed no significant interval change from the one previously done. • On the 38th HD, • ABG showed partially compensated metabolic alkalosis.

  33. Course in the Wards • On the 39th HD • ABG showed fully compensated metabolic alkalosis. • CXR: partial clearing of the pneumonia opacities bilaterally, there is partial resolution of the right sided pleural effusion and the rest of the lung finding is stationary. • On the 48th and 51st HD • ABG showed fully compensated metabolic alkalosis. • On the 60th -63th HD • the patient was tried to wean from the mech vent but the patient did not tolerate. ABG was done thrice. • On the 67th HD • CXR: clearing of the pulmonary edema or pneumonia and non-specific interstitial infiltrates are seen in the right upper lung area.

  34. Aspiration Pneumonia Outcome: Improvement

  35. Multiple Electrolyte Abnormalities 3/22/10

  36. Course in the Wards • Upon admission • Na and K were requested which revealed hypokalemia (3.25mmol/L) and hypernatremia (147.15mmol/L). • Kaliumdurule 2 durules TID for 3 doses was then given. • Repeat Na and K was done and showed normal results. • On 4thHD • Repeat Na and K showed hypokalemia ( 2.93), KCL drip 40mEq in 80cc PNSS for 3 doses was started and Kaliumdurule 2 durules initially then 1 durule TID for 3 doses were given. • Repeat serum K was done the following day and showed normal potassium. • On 8thHD • Repeat Na and K showed hypokalemia (3.27), Kaliumdurule 2 durules initially then 1 durule TID for 3 doses were given. Repeat potassium showed normal value of 4.26 mmol/L.

  37. Course in the Wards • On the 21st HD • Na and K showed hypokalemia (3.61). Patient was then given Kaliumdurule TID for 6 doses. Repeat Na and K then showed increase in K to 3.76. • On the 23rd HD • Na and K showed hypokalemia (3.68). On the 25th HD, K results were normal (3.98) and Kaliumdurule was discontinued. • On the 33rd HD • Patient was hypokalemic (3.5) Kaliumdurule TID, 1 durule for 6 doses was given. • On the 41st HD • Patient was assessed to have hyponatremia (125.57) probably secondary to SIADH. NaCl tab 1 tab TID was given.

  38. Course in the Wards • On the 45th HD • Na (140), K (3.96), Mg (2.35), and iCa (1.15) were all normal. • On the 50th HD • Na was slightly decreased (136) and potassium was normal (4.09). On the 54th HD, Na (137) and potassium (4.33) became normal. • On the 73rd HD • Potassium was low (2.75) and Kaliumdurule was started 1 dose qid x 6 doses was given. • On the 74th HD • Potassium was 3.67 and repeat potassium was 3.65. Kaliumdurule was discontinued. • On the 85th HD • Potassium levels was 3.05 so Kaliumdurule was given. • On the 86th HD • Repeat potassium showed improvement of 4.09 so Kaliumdurule was discontinued.

  39. Course in the Wards • On the 92th HD • Potassium results showed 3.41; hence kaliumdurule was once again started, given for 1 day. • On the 93rd HD • Potassium and sodium was normal at 3.89 mmolo/l and 144 mmol/l • On the 95th HD • Potassium was low at 2.75 and sodium was normal at 141.03 and KCl drip was started at 40 meqs in 80 cc PNSS for 4-6 hours. Kaliumdurule 1 dose qid x 8 doses was given also. • On the 97th HD • Potassium was low at 3.26 and sodium was normal at 138. Kaliumdurule 1 durule at TID for 6 more doses was given. • On the 102nd HD • Potassium was low at 2.03 and sodium was normal at 140 and NaHCO3 was discontinued. Kaliumdurule at 3 durules then 2 durules QID for 6 doses was given. Kcl drip at 20 meqs in PNSS over 6 hours for 2 doses was started. • On the 103rd HD • Repeat sodium and and potassium was requested and revealed hypokalemia of 3.44 and normal sodium (137). The 1stKCl drip was to be consumed and 2nd dose was discontinued and kaliumdurule was decreased to 1 durule TID for 6 doses.

  40. Multiple Electrolyte Abnormalities Outcome: Unresolved, recurring

  41. Hospital Acquired Pneumonia 6/22/10

  42. Course in the Wards • On the 92ndHD • Patient was noted to be febrile at 38°C and was started on clindamycin 300 mg/tab q6 and ciprofloxacin 250 mg/tab BID. • On the 95thHD • Patient had 6-7 episodes of loose bowel movement with yellowish brown stools and noted mucoid consistency but non-foul smelling and clindamycin was shifted to metronidazole 500mg/tab 1 tab q8 • On the 101stHD • There was noted decreased breath sounds on bilateral lung and chest x-ray was requested with the impression to consider pneumonia on the right lung base, minimal pleural effusion, bilateral. • On the 102ndHD • Patient was to be shifted from ciprofloxacin to cefoperazone_sulbactam 1.5 gm/IV q 8hr however was not available due to financial constraints. Ciprofloxacin 250 mg/tab 1 tab BID was then continued. • On the 106th HD • Patient would develop febrile episodes and Fluconazole and Metronidazole was started

  43. Hospital Acquired Pneumonia Outcome: Unresolved

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