OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: DELA ROSA, CORAZON Age/Sex: 68/F Address: 1390 Rd.1 Bo Obrero St., Pandacan, Manila Date of admission: March 18, 2008 Admitting Diagnosis: Acute Respiratory Failure 2° to CAP HR č Sepsis PTB IV DM Suspect Residents in charge: Dr. Esmero, Estrada, Cortes Clerk-in-Charge: Florentino/Ingles
Hospital #: 1813396
24 Hour History
This is a case of a 68 year-old female who was admitted due to difficulty of breathing. History of Present Illness One month prior to admission, the patient has productive cough with whitish sputum, but no dyspnea. She experienced occasional afternoon fever, had weight loss and body weakness. No consult was done. She self medicated with Salbutamoland Guiafenesin, there was some relief of cough. Three days prior to admission, patient has productive cough with yellowish sputum, with fever of 38°C, had difficulty of breathing on exertion, easy fatigabilty, general body weakness and 3 pillow orthopnea. No cyanosis, no chest pain, no edema, no abdominal pain, no change in bowel habit. No consult and no meds given. Two days prior to admission, the patient had on and off fever at daytime, progression of dyspnea, anorexia and body weakness. No consultation done. Few hours prior to admission, there was increased in the severity of dyspnea, hence consult. Past Medical History Diagnosed case of PTB since 1998, but underwent treatment for 6 months last 2007. Diagnosed hypertensive since 2006, maintained on PRN Nifedipine. Usual or highest BP unknown to the informant. No allergy, no asthma, no previous operation. Family History (+) DM – mother side (+) CKD – father side no family history of HPN Personal and Social History Non smoker Non alcoholic beverage drinker Review of Systems HEENT: (-) headache, (-) dizziness, (-) blurring of vision, (-) gum/nose bleeding, (-) tinnitus Cardiac: (-) chest pain, (+) palpitations, (+) PND Gastrointestinal: (-) abdominal pain, (-) melena, (-) nausea and vomiting Genitourinary: (-) dysuria, (-) hematuria, (-) oliguria Endocrinology: (+) polyuria, (+) polyphagia, no heat/cold intolerance Hematology: no easy bruisability Musculoskeletal: (-) myalgia, (-) arthralgia Neurologic: (-) seizure, (-) loss of consciousness Physical Examination: conscious, coherent, in respiratory distress Vital Signs: BP: 130/80 HR: 88 RR: 24 Temp: 36 SKIN: no pallor, no cyanosis, moist warm extremities HEENT: pale palpebral conjunctivae, anicteric sclerae, no alar flaring, no cervical lymphadenopathies, no neck vein distention CHEST AND LUNGS: symmetrical chest expansion, (+) supraclavicular retractions, (+) diffuse crackles, no wheeze HEART: adynamic precordium, PMI 5th LICS MCL, tachycardic, regular rhythm, no murmur ABDOMEN: flat, normoactive bowel sound, soft, non-tender EXTREMITIES: full equal peripheral pulses, no edema Assessment: Acute Respiratory Failure 2° to CAP High Risk č Sepsis PTB IV DM Suspect
Plan: for Admission The patient was admitted to 424 under the service of Drs. Payumo/ Esmerol/ Estrada/ Cortes and secured consent for admission and management. NGT was inserted. TPR every shift and recorded, Input and output was monitored and recorded every shift. Patient’s diet was OF feeding at 1800 kcal/day in 3 divided meals. IVF was PNSS 1L for 12 hours.
Laboratory procedures were requested: CBC c PC, CBG, CXR-PA, ECG, Blood C/S, ETA GS/CS, Sputum GS/CS, Sputum AFB for 3 days, BUN, CREA, Na, K, ABGs, TG, Chole, HDL, LDL, BUA, FBS Under the following medications: Ceftazidime 1 g TIV every 8 hours ANST Azithromycin 500 mg TIV OD ANST, if N/A 500g 1 tab OD/NGT Paracetamol 300g/mg 1½ mg TIV every 4 hours PRN for fever Salbutamol nebulization q 4 Dopamine drip (Premizel) 30 gtt/min (10nbd@45kg) Patient was for referral to service consultant. Vital signs were monitored every hour and CBG every 6 hours. She was placed to moderate to high back rest. Secretions suctioned every hour. Patient was watched out for hypotension and fever. On admission, the patient was maintained on NGT, OF was continued, IVF was PNSS 1L for 12 hours. The previously requested labs were carried out and followed up. The patient was for ABG, FBS, HgbA1c. The medication was continued. Patient was in continued manual ambobagging if mechanical vent was not available. She was placed to moderate to high backrest. Input and output was monitored, vital signs and urine output were monitored every hour and CBG every 6 hours. Patient was watched out for cyanosis and DOB. On the 1st hospital day, patient was maintained on NGT, OF was continued, IVF was PNSS 1L for 12 for 12 hours. Dopamine drip was decreased to 18 gtts/min. (5mkd/50kgs). Patient was requested for the following laboratory tests: Blood C/S-2 sites, ABG, ETA GS/CS and AFB, TG, Chole, LDL, HDL, BUA, FBS. Medication was continued. She was placed to moderate to high back rest. Manual ambobagging at 02 10cpm was done because mechanical vent still not available. Vital signs monitored every hour, input and output was monitored. Patient was watched out for DOB, decrease in BP and fever. Patient was then hooked to mechanical vent at the following settings: F102- 100, AC mode, BOR- 16, TV- 400. ABG 1 hour post hooking to MV was done. Secretions suctioned every hour and PRN. Dopamine drip was decreased to 11 ugtts/min (3mkdx5kg) to maintain BP ≥90/60.