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.