Welcome to the official website of the Department of Internal Medicine, Visayas Community Medical Center, Cebu City, Philippines [tel # 032-253-1901, loc 291]
   
  Visayas Community Medical Center : Department of Internal Medicine
  M&M Protocol
 

VISAYAS COMMUNITY MEDICAL CENTER

Department of Internal Medicine

Osmeña Boulevard, Cebu City

 

Activity

Morbidity and Mortality Conference

Date/Time

November 30,2008 / 8:30 A.M.

Venue

VCMC Conference Room

Presenter

Edward Alexis R. Caballero, M.D.

 

Case:       

                M.T., 35F married, housewife from Aurora, Zamboanga Del Sur, admitted for the 1st time at VCMC on October 19, 2009 due to cough and dyspnea.

                Patient is non-hypertensive, non-diabetic, and non-asthmatic. Patient is allergic to paracetamol and has no known food allergies. Previous hospitalizations are as follows:

                December 2008 at Aurora General Hospital for vaginal bleeding & anemia, IUD was removed, 1u PRBC transfused.

                February 2009 at Aurora General Hospital later transferred to Hofilena Hospital in Pagadian City for epigastric pain, UTZ was unremarkable. Patient’s epigastric pain subsequently relieved with unrecalled medications.

                July 2009 at Hofilena Hospital at Pagadian City for dyspnea. Patient claims no definite diagnosis was given to them, workups done were unrecalled but had included a normal echocardiography. Medications given to patient during hospitalization and on discharge were metoprolol, digoxin & paracetamol. Patient had received other unrecalled medications. Patient was discharged after several days only slightly improved.

                Patient is a housewife. Non-smoker and non-alcoholic beverage drinker.

               

History of Present Illness:

 

Problem: Cough & Dyspnea:

                3 months PTA noted onset of cough, with whitish sputum, associated with undocumented low grade fever and body malaise. Patient was admitted at Hofilena Hospital in Pagadian City. Patient recalls that the expensive workups  had revealed no definitive diagnosis apart from knowing that 2DED had been normal and patient was given digoxin & metoprolol. Patient claimed she was discharged after several days only slightly improved. Patient had limited physical activity due to exertional dyspnea. Since then patient has been having on and off fever, cough & persistent fatigue. Patient tolerated the condition due to financial constraints.

                1 week prior to admission, patient noted more frequent bouts of cough, this time with purulent sputum and intermittent undocumented fever. Dyspnea had progressed, with dyspnea being noted at rest. On advice of patient’s sister, family decided to bring patient to Cebu and subsequently to this institution for admission.

 

Physical Examination

Patient was alert, ambulates with support, coherent, febrile & tachypnic with the following vital signs:

BP: 70/50mmHg  HR: 124bpm         RR: 28cpm            Temp: 39.7ºC       Wt: 42kg

Skin: pale palms, diaphoretic, no skin lesions

Neck: no neck vein engorgement, no lymphadenopathy

HEENT: anicteric sclerae, pale palpebral conjunctivae

Neck: supple, no neck vein engorgement

C/L: ECE, fine inspiratory rales bibasal, no wheezing

CVS: distinct S1 & S2, tachycardic, regular rhythm, no murmurs

Abdomen: flabby, soft, normoactive bowel sounds, no tenderness, no masses

GUT: no costovertebral angle tenderness

Extremities: no deformities, CRT <2secs.

                CNS: WNL

 

IMPRESSION:      (1) Sepsis due to Community Acquired Pneumonia, High Risk

                                (2) T/C PTB3

                                (3) Anemia of Chronic Disease

                          

Course in the Ward:

                On admission, she was admitted under charity service, fluid resuscitation of 1.2L was given. CXR showed pneumonia, bilateral pleural effusion & marked cardiomegaly with a CT ratio of 0.64. CBC showed leukopenia (WBC 3.2k/uL) & anemia (Hgb 7.9g/dL). Piperacillin-tazobactam was started. Patient’s BP responded to fluid resuscitation. Urine output was adequate. Urinalysis from Foley catheter showed trace protein & RBC 8-12/HPF. Peripheral smear showed Microcytic, normochromic anemia, mild leukopenia with neutrophil predominance. Reticulocyte count was 1.3%, Reticulocyte index was 0.8%, 2 units of PRBC were ordered to be transfused.

                On the 1st hospital day, patient was still febrile & dyspnic, BP ranged 80-110/60-70mmHg, HR 90-110s. Direct Coombs’ test was ++, indirect Coombs’ test was negative. 2DED showed mild pericardial effusion and normal LV dimension. ANA was negative. Repeat UA showed persistence of microscopic hematuria (RBC 13-16/HPF).

                On the 2nd hospital day, fever lysed. Patient was seen by a Cardiologist for consult regarding the pericardial effusion and suggested to continue workup for rheumatic etiology. 2 units of PRBC were transfused. Patient still complained of malaise but noted slight relief of dyspnea.

                On the 3rd hospital day, LDH was elevated (496 U/L). Autoimmune hemolytic anemia criteria was fulfilled. Prednisone 60mg/day PO was started. Patient was referred for comanagement with charity hematologist consultant. 24H urinary protein was elevated 533 mg/24H. Patient was seen by charity rheumatologist consultant and further workup was suggested in order to fulfill criteria for definite SLE. Piperacillin-tazobactam was shifted to levofloxacin PO.

                On the 4th hospital day, patient claimed improvement of general wellbeing and dyspnea. Serum C3 was low (0.6 g/L).

                On the 5th hospital day, anti-DSDNA result became available and was positive (+). Patient continued to clinically improve.

                On the 6th hospital day, repeat CXR showed regression of the bibasal inflammatory process. Repeat CBC showed improvement of leukopenia (WBC 8.45k/uL from 2.21k/uL). Patient was discharged improved and advised close follow-up as outpatient.

 

Final Diagnosis:  (1) Systemic Lupus Erythematosus, in flare

(2) Severe Sepsis due to Community Acquired Pneumonia, High Risk

 

 

SUMMARY OF LABS:

 

 

 

Oct. 19

Oct. 20

Oct. 22

Oct. 23

Oct. 24

Oct. 25

CBC

 

 

 

 

 

 

WBC

3.22

 

2.21

 

 

8.45

N

73.3

 

72.4

 

 

82.3

L

9.3

 

11.3

 

 

5.1

M

17.4

 

14

 

 

12.5

E

0

 

2.3

 

 

0.1

B

0

 

0

 

 

0

MCV

77.7

 

78.3

 

 

78.7

MCH

24.8

 

25.6

 

 

25.6

MCHC

32

 

32.7

 

 

32.5

Hgb

7.9

 

12.6

 

 

12.0

Hct

24.7

 

38.5

 

 

36.9

Platelet

382

 

397

 

 

373

Retic Ct

1.3%

 

 

 

 

 

Urinalysis

 

 

 

 

 

 

Color

Lt Yellow

Yellow

 

 

 

 

App

Sl. Cloudy

Sl. Cloudy

 

 

 

 

pH

6.5

7.0

 

 

 

 

Sp. Gr.

1.010

1.020

 

 

 

 

Protein

Trace

Trace

 

 

 

 

Glucose

-

-

 

 

 

 

RBC

8-12

13-16

 

 

 

 

WBC

2-4

1-3

 

 

 

 

EC

Rare

Few

 

 

 

 

Creatinine

0.42 mg/dL

 

 

 

 

 

SGPT

23 U/L

 

 

 

 

 

Serum Na+

138 mmol/L

 

 

 

 

 

Serum K+

3.2 mmol/L

 

 

 

 

 

Protime

 

 

 

 

 

 

Patient

12.0 sec

 

 

 

 

 

Control

12.3 sec

 

 

 

 

 

Px %Act

96.3%

 

 

 

 

 

INR

1.01

 

 

 

 

 

Coombs’ Test

 

 

 

 

 

 

Direct

 

++

 

 

 

 

Indirect

 

-

 

 

 

 

FBS

 

89 mg/dL

 

 

 

 

TSH

 

3.41 uIU/mL

 

 

 

 

FT4

 

18.5 pmol/L

 

 

 

 

ANA

 

Negative

 

 

 

 

Total Bilirubin

 

 

0.22 mg/dL

 

 

 

Direct Bilirubin

 

 

0.07 mg/dL

 

 

 

Indirect Bilirubin

 

 

0.15 mg/dL

 

 

 

LDH

 

 

496 U/L

 

 

 

24h Urine Protein

 

 

533 mg/24h

 

 

 

Serum C3

 

 

 

0.6 g/L

 

 

Anti-DSDNA

 

 

 

 

+1

 

 

OTHERS:

Oct. 19: ECG: Sinus tachycardia, non-specific t wave changes

 

Oct. 19: CXR: Consider inflammatory process as in pneumonia in both lower lobes with bilateral pleural effusion.

   Marked cardiomegaly with evidence for pulmonary congestion. Dense minor fissure which may relate to the

   presence of fluid or thickening.

 

Oct. 19: Peripheral Smear: Microcytic, normochromic anemia with moderate anisopoikilocytosis. Mild leukopenia with

   Neutrophil predominance and relative monocytosis. Adequate thrombocytes.

 

Oct. 20: 2DED: Normal left ventricular dimension with adequate contractility and systolic function but with doppler

   Evidence of biventricular diastolic dysfunction. Mild pericardial effusion.

 

Oct. 21: UTZ-Whole Abdomen: Coarsely echogenic liver echotexture associated with posterior attenuation sound. This

   raises the question of fatty liver versus early liver cirrhosis. Negative gallbladder, pancreas and splenic sonogram.

   Bilaterally enlarged kidneys. This finding raises the question of bilateral pyelonephritis. Negative right and left

   ureteral sonogram. Negative pelvic sonogram.

 

 


Visayas Community Medical Center

Department of Internal Medicine

 

Morbidity and Mortality Conference

Case Protocol

 

Presenter: Dr. Shoji S. Mantilla

Moderator:  Dr. Brett Batoctoy

VCMC Board Room September 28, 2009, 8:30am

 

General Data:

 

B.E. 87years old, Female, Widow, Retired teacher from Guadalupe, Cebu City admitted to this institution due to Cough and Body Malaise

 

Non Smoker, Non Alcoholic, Non Diabetic, Non Asthmatic, Known Hypertensive for 2 years  Usual BP:  130-140/90 Highest BP:  150/100 Maintenance : Micardis 40mg OD  Inderal 10mg OD

 

Previous Hospitalization:

                 2007 Dec              : Hip Fracture due to fall, S/P Hip replacement

                 2008 Oct              : Hip Fracture due to another fall, no surgical intervention

 

History of Present Illness

 

                2 Weeks PTA, Noted onset of on & off productive cough with whitish sputum, Associated with body malaise, No Febrile episodes, Condition Tolerated

                3 Days PTA Sign and symptoms persisted, Thus IV was started at home with PNSS 1l @ 10ggts/min by her daughter (OBGYNE),                Cefuroxime 750mg IVTT Q8H was also started

                AM PTA Due to persistence of cough and body malaise inspite of the medications that lead to seek admission

 

Physical Examination

 

BP           :  150/90  HR:  88 RR: 22 temp: 36.2 Weight: 40kgHeight: 5ft  BMI: 17.22 kg/m2

 

Sthenic, Conscious, Coherent, Cooperative, Not in Respiratory Distress

Skin         :  Soft, warm, senile turgor

HEENT     : Anicteric Sclerae, Pink Palpebral conjunctiva

C/L          : Equal Chest Expansion, (+) Rales: Left Lower Lobe

CVS         : Distinct Heart Sound, Normal Rate Regular Rhythem

Abd         : Flat, Soft, Normo Active Bowel Sounds, No Mass noted

GUT         : (-) Kidney Punch Sign

Ext           : Full Pulse, Negative Edema

 

Course in the Wards:

               

On Admission, patient noted to be conscious, coherent, cooperative and not in respiratory distress. Laboratories taken: ABG: Metabolic Alkalosis with concomitant Respiratory alkalosis, Hypokalemia: 2.9, Chest X-ray: Interval Appearance of bilateral pleural effusion more on the left. Concomitant inflammatory process in both lower lobes is also considered, 2D Echo with Doppler, Concentric Left Ventricular Hypertrophy with adequate contractility and systolic function but with doppler evidence of biventricular diastolic dysfunction, Tricuspid Regurgitation, Severe Aortic Sclerosis with Aortic Regurgitation 1+ Sever pulmonary Hypertension Incidental Findings of Left Pleural Effusion. Kalium durule, Telmisartan, propanolol, piperacillin-tazobactam was started. Impression: Community Acuired Pneumonia-Moderate Risk, Hypertensive cardiovascular disease, Malnutrition

4th Hospital Day, Patient noted to be dyspneic, disoriented ABG  @ 10lpm showed Metabolic Acidosis with Respiratory Acidosis pH 7.263 pCO2 102.3 pO2 36.3 HCO3 45.1 O2Sat 62.1, ECG: Sinus Tachycardia with IVCD, Non Specific ST wave changes, CXray:  Interval development of a Left Upper Lobe Pneumonia, with progression of the pleural effusion and pneumonic process in the right lower lobe. Salbutamol nebulization done, ambroxol, clopidogrel was given. Impression: Acute Respiratory Failure secondary to CAP, HCVD and Malnutrution

10th Hospital Day, Patient was comfortable, no subjective complaint, V/S stable, Weaning was tried but patient noted to be dyspneic thus weaning was deferred. Thus Mechanical Ventilator was change to Mechanical Ventilator with SIMV mode. Impression: Acute Respiratory Failure secondary to CAP, HCVD and Malnutrution

15th  Hospital Day, Patient no subjective complaint, V/S stable, patient underwent Thoracentesis, Tracheostomy and PEG insertion. Due to persistent pleural effusion of Left, poor respiratory process and poor appetite. Impression: Acute Respiratory Failure secondary to CAP, HCVD and Malnutrution

 

20th Hospital Day, Patient condition improved with the Tracheal Mask, Medications was continued, Pulse Oximeter and Cardiac Monitor was discontinued. Medications and Blenderized feeding was continued. And subsequently discharge at the 29th day of Hospitalization.

 

Diagnosis:

1.       Community Acquired Pneumonia – Moderate Risk

2.       Hypertensive CardioVascular Disease

ABG

Day 1

Day 4

30 mins after Mech Vent

Day 6

Day 10

Weaning

Day 14

Day 15

Day 21

Day 23

Day 25

                     

FiO2

RA

NP    

10LPM

MV   

100%

MV   

 45%

TP 

4LPM

MV

40%

MV

40%

TM

5LPM

TM

3LPM

TM

2LPM

pH

7.456

7.263

7.525

7.503

7.398

7.431

7.705

7.414

7.415

7.400

pCO2

66.8

102.3

47.4

43.1

57.3

60.1

27.3

47.6

55.8

62.1

pO2

43.7

36.3

117.5

56.6

54.7

78.9

54.6

317.2

269.2

175

HCO3

47

45.1

39.1

33.1

39.5

39.1

35

29.7

35.4

37.6

O2sat

83

62.1

98.7

92.4

88.7

96.3

94.2

99.9

99.7

99.6

pAO2/

FiO2

208

36.3

117.5

119

136

197

136

634

897

875

3.        Malnutrition

 

Labs:

CBC

Day 1

Day 4

Day 5

Day 6

After BT 1

Hgb

13.60

12.53

9.90

11.10

Hct

44.70

37.60

34.20

34.30

platelet

258

195

185

168

WBC

6.63

11.37

11.03

9.65

Seg

82.10

86.90

91.90

85.70

Lymp

10.30

4.70

2.90

5.80

Mono

6.50

8.00

5.90

7.80

Eos

0.90

0.30

0.10

0.60

Baso

0.20

0.10

0.00

0.10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blood

Chemistry

Day 1

Day 5

Day 13

Day  17

Day 21

Na

140

134

134

129

133

K

2.9

3.7

3.0

3.5

4.3

Crea

0.49

0.65

     

Trop I

 

<0.2

     

VISAYAS COMMUNITY MEDICAL CENTER
Department of Internal Medicine
Osmeña Boulevard, Cebu City

Activity          Morbidity and Mortality Conference
Date/Time    July 27,2008 / 8:30 A.M.
Venue           VCMC Conference Room
Presenter     Edward Alexis R. Caballero, M.D.
Moderator:  Arlene Kuan, MD, FPCP

Case:    
    E. D. L. P. 60F married, retired teacher from Mabolo, Cebu City, admitted for the 1st time at VCMC on May 19, 2009 due to fever.
    Patient is non-hypertensive & non-asthmatic. Known diabetic for about 4 years w/ good compliance to metformin PO but with poor follow-up. No previous hospitalizations. No food and drug allergies. No known HFD. Non-smoker & non-alcoholic beverage drinker.
    Menarch was at 13y.o., menstruations lasting 4 days, consuming 2-3 napkins per day w/ no dysmenorrhea. 1st sexual contact was at 25y.o. w/ husband as sole sexual partner. OCP but discontinued on 1979. G2P2002, all deliveries NSD and uncomplicated.

History of Present Illness:

Problem #1: Fever
    2 weeks PTA, patient noted onset of low grade fever & malaise, no cough and no dysuria were noted. Petechial rashes were noted on the legs. Condition was tolerated.
    8 hours PTA, high grade fever w/ chills and severe body malaise was noted. Patient subsequently decided to seek admission.
 
Problem #2: Pallor
    About 2 months prior to admission was noted to be pale. Easy fatiguability also noted but was tolerated. No consults done. No history of melena nor hematochezia.

Problem#3: Breast mass
    1 year PTA, patient noted a small mass on the left breast, painless, growing gradually, which she did not disclose to her family. Gradual weight loss of about 10% of body weight noted at 6 months PTA. Condition was tolerated. No consults were done.

Problem #4: Diabetes Mellitus type 2
    Polyuria and polydypsia noted about 5 years PTA. Patient subsequently diagnosed with T2DM 4 years PTA, w/ poor compliance to metformin & poor follow-up.

Physical Examination
Patient was alert, coherent, febrile & not in respiratory distress with the following VS:
BP: 110/60 mmHg    HR: 119 bpm    RR: 20 cpm    Temp: 39.7ºC    Wt: 43kg
Skin: warm, good turgor
HEENT: anicteric sclerae, pale palpebral conjunctivae
Neck: supple, no neck vein engorgement
Axillae: hard, fixed, non-tender 2x2cm lymph node left axilla
C/L: ECE, clear breath sounds, no rales, no wheezes
Breasts: (+) hard, fixed, non-tender 8 x 10cm mass at 3 o’clock position on the left breast w/ brawny
desquamation surrounding the nipple. No nipple discharges.
CVS: distinct S1 & S2, tachycardic, regular rhythm
Abdomen: flabby, soft, normoactive bowel sounds, distended hypogastric area
GUT: no costovertebral angle tenderness
Extremities: no rashes. CRT <2secs.
    CNS: WNL

IMPRESSION: (1) UTI
               (2) Anemia likely due to malignancy
               (3) Breast mass likely malignant
               (4) Diabetes Mellitus type 2



Course in the Ward:
    On admission, patient was started on O2 inhalation, venoclysis was started, CBC showed pancytopenia (WBC-1.63k/uL, Hgb-5.33, Platelet-10k/uL) & severe neutropenia (ANC-4/uL). CBG was 363mg/dL. ECG showed sinus tachycardia w/ early repolarization pattern & nonspecific ST segment and T wave changes. CXR showed no infiltrates, a nodular density on superimposed on the 6th posterior rib on the left, which corresponded clinically to the L axillary lymph node. 3 units of PRBC were ordered to be secured and transfused. A donor for platelet apheresis was sought for. Regular insulin was given to control the blood glucose.
    On the 1st hospital day, had episodes of fever up to 39.5C, BP range 110-160/60-80mmhg, HR 82-100. CBG ranged 123 – 367 mg/dL. UA was unremarkable. Peripheral smear showed normocytic normochromic anemia w/ moderate anisopoikilocytosis, leukopenia w/ relative lymphocytosis, thrombocytopenia.  Reticulocyte count was 0.2%, Reticulocyte index was 0.07%. Ceftazidime 500mg IV q8H was started. 1 unit of PRBC was transfused. Patient was referred to GS re the breast mass.
    On the 2nd hospital day, fever lysed. Vital signs were stable. Patient was comfortable but still with poor appetite. CBG ranged 123 – 367mg/dL. She was seen by GS department. Core needle biopsy was advised but patient was undecided. BMA was planned but patient would not consent. 2nd unit of PRBC was transfused.
    On the 3rd hospital day, patient had stable vital signs and was comfortable. CBG ranged 115 – 414mg/dL. Patient was still undecided regarding BMA and core needle biopsy. 3rd unit of PRBC was transfused.
    On the 4th hospital day, patient was noted w/ sudden onset of unresponsiveness. Patient was comatose. BP 140/90 w/ Cheyne-Stokes respiration. Patient was intubated and attached to a mechanical ventilator. CTscan of the brain w/o contrast was taken and showed Intracerebral hemorrhage, on the right basal ganglia and midbrain approximately 13cc, with intraventricular extension. Repeat CBC showed Hgb-9.14g/dL WBC-1.29k/uL Platelets-8k/uL. Tranexamic acid, Vitamin K, Citicholine, Mannitol & Piracetam were started. Hypotension was subsequently noted thus dopamine drip was started. Patient went into cardiac arrest and was resuscitated successfully. Family was appraised. Family subsequently decided to withhold aggressive measures. Patient subsequently went into another cardiopulmonary arrest and was pronounced dead.


Final Diagnosis:

(1) Intracerebral bleed, right basal ganglia secondary to thrombocytopenia, secondary to bone
marrow infiltration, secondary to breast cancer stage 4.
(2) Diabetes Mellitus type 2


SUMMARY OF LABS:

TESTS    5/19    5/20    5/21    5/23
CBC
Hgb       5.33g/dL            9.14g/dL
Hct        16.0%                25.7%
WBC     1.63k/uL            1.29
  Stab         0%                0%
  Seg        2.5%               4.7%
  Lymph    96.3%            95.3%
  Mono       1.2%              0%
  Eos           0%                0%
  Baso         0%            0%
  Others                
Platelets    10k/uL            8k/uL
Blood Typing    O’+’            
Retic. Count    0.2%            
Retic. Index        0.07%            
Coombs Test, Direct    2+            
Coombs Test, Direct    1+            
CK-MB    6 U/L            
Troponin-I    (-)            
Protime
   Control    10.6 secs            9.75 secs
   Patient    11.3 secs            10.2 secs
   % activity    96%            108%
   INR             1.02            0.96
APTT                
   Control    28.7 secs            
   Patient    22.2 secs            
Crea    0.58mg/dL            
Serum Na    140mg/dL            
Serum K    4.0mg/dL            
SGPT    15 U/L            
LDH    363 U/L            
Alkaline Phosphatase    90 UL            
Urinalysis                
Color                   Yellow        
Appearance        Sl. Cloudy        
pH                        6.0        
Sp. Grav            1.011        
CHON             Negative        
Glucose            3+        
RBC              3-5/HPF        
WBC              0-1/HPF        
E.C.                Rare        
Bacteria        Rare        
Blood            Negative        
Urinary Ketone        Negative        

OTHERS:
May 19: ECG: Sinus tachycardia w/ early repolarization pattern, nonspecific ST-T wave changes.

May 19: CXR: Nodular density superimposed on d 6th posterior limb on the left rib. Atheromatous thoracic aorta.  Spondylosis of dorsal spine

May 20: Peripheral Smear: Normocytic normochromic anemia w/ moderate anisopoikilocytosis, leukopenia w/ relative  lymphocytosis, thrombocytopenia

May 21: UTZ-KUB: Normal KUB

May 23: CT scan of the brain w/o contrast: Intracerebral hemorrhage, R basal ganglia and midbrain approximately 13cc in volume w/ intraventricular extension.



 
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