Docstoc
EXCLUSIVE OFFER FOR DOCSTOC USERS
Try the all-new QuickBooks Online for FREE.  No credit card required.

santos_death protocol

Document Sample
santos_death protocol Powered By Docstoc
					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: SANTOS, LUZ Age/Sex: 78/F Address: 1157 Zapanta St. Singalong Manila Date of admission: August 4, 2007 Admitting Diagnosis: Diabetic Ketoacidosis Community Acquired Pneumonia, Moderate Risk DM type 2 HCVD, NSR, II B Residents in charge: Drs. Fuentes/Aguila/Receno/Dimaandal Intern-in-Charge: Ryan Escandor Clerk-in-Charge: Palay/Rentillo/Roxas

Hospital #: 1715865

Death Protocol This is a case of a 78 year-old female who came in due to generalized body weakness History of Present Illness Patient is a diagnosed case of DM type 2 since 2002. Maintained on glipizide and intermediate insulin 18/10 with oor compliance, s/p BKA (2003) at medical center manila. She was apparently well until.. 5 days PTA, patient had loose stools, abdominal pain and generalized body weakness. Consulted at OMMC ER with diagnosis of AGE some signs of dehydration, HCVD, DM type2. Given home meds pf Pelindopril, Glipizide, ORS 3 days PTA, there was persistence of generalized body weakness. No abdominal pain nor vomiting. No consult done Few Hrs PTA, persistence and increased severity generalized body weakness prompted consult hence the admission. Past Medical History (-)BA Family History (+) DM mother and father side Personal and Social History Nonsmoker and nonalcoholic beverage drinker Review of Systems Constitutional: (+) anorexia, (+) weight loss HEENT: (+) BOV, (-) tinnitus, (+) hearing loss Respiratory: (-) cough (-) colds (-) hemoptysis Cardiovascular: (+) easy fatigability, no chest pain Physical Examination: Awake to drowsy Vital Signs: BP: 120/100 HR: 98 RR: 18 Temp: 37 HEENT: pink palpebral conjunctivae, anicteric sclerae, no alar flaring, no mass, no neck vein engorgement, no nasoaural discharge, no cervical lymphadenopathies CHEST AND LUNGS: symmetrical chest expansion, - retraction, no lags, clear breath sounds HEART: adynamic precordium, no heaves, no thrills, PMI at 5th ICS AAL, NRRR, no murmur ABDOMEN: flat, normoactive bowel sound, soft, non tender, no mass EXTREMITIES: full equal pulses, no edema, no cyanosis, (+) amputation left lower extremities Assessment: Diabetic Ketoacidosis Community Acquired Pneumonia, Moderate Risk DM type 2 HCVD, NSR, II B PLAN: For admission Patient was admitted to the service of Drs. Fuentes, Aguila, Receno, and Dimaandal. Consent for admission and management was secured. She was hooked to IVF: PNSS 1L x 6 hours to be followed by another 2 PNSS 1L x 6 hours. She was placed on NPO. Laboratory procedures requested were RBS q1, CBC with platelet count, urinalysis, CXR PA, ECG, ABGs, FBS, BUN, creatinine, Na+, K+, HDL, LDL, TG, cholesterol, BUA, HgA1C. Medications ordered were Coamoxiclav 1.2g TIV, Clarithromycin 500mg 1 tab BID, Salbutamol nebulization PRN for dyspnea, PAracetamol 500mg TIV q4 PRN for T≥38.5C. Regular Insulin 5 u SL PRN with CBG≥250mg/dL, Pelindopril 2mg/ tab OD, captopril 25 mg/ tab SL PRN BP≥160/90. She is on a moderate to high back rest. O2 was given at 2-4 lpm via nasal cannula. VS monitored q1 with CBG and UO monitoring and to WOF hyper/hypoglycemia, changes in sensorium and respiratory distress. Upon admission, patient is placed on NPO except meds. IVF to follow were R: D5 0.45 1L x 6 hours, L: D5 0.45 1L x 6 hours. Previously ordered labs were still requested. Medications were continued. Foley catheter was inserted. U and I and o Moniotred q1. VS also monitored q1 with CBG. Still hooked to O2 support via nasal cannula at 2-4lpm. She is still on a moderate high back rest. To WOF Hyper/hypoglycemia, hypotension and decrease in UO

On the 1st hospital day, IVF shifted to PNSS x 6 hours.followed by 500cc. CVP insertion with surgery referral was requested once with consent and will be monitored q1. NGT was inserted and OF feeding started at 1500kcal divided into 3 feedings with fluids provided every meal. Additional labs requested were repeat potassium, Cl, Mg, PO4, FBS, HBA1C, lipid profile, BUA, 12LECG daily, ABGs, Blood culture x 2 sites, repeat urine ketones, serum ketone and KUB UTZ once stable. Co amoxiclav shifted to ceftriaxone 2 g TIV OD, Clarithromycin shifted to Azithromycin 2 gm SD. Paracetamol 500mg 1tab PRN per NGT. Regular insulin drip PNSS .9 +10u Humulin R to run x I hr via soluset. Salbutamol nebulization on hold, Pelindopril 2mg/ tab OD per NGT, captopril 25 mg/ tab SL PRN BP≥160/90, Omeprazole 40 mg 1 amp TIV OD with glucose goal of 150-250mg/dL. May give D5 0.3 NaCl 1L or D5NSS IL at 100ml/hr if NA D5 0.45% when plasma glucose reaches 250mg/dL. IFC was inserted. VS monitored q1 with CBG and UO monitoring NVS q4and to WOF hyper/hypoglycemia, changes in sensorium and respiratory distress. Endocrine service consultant suggest Insulin drip 4u per hour. Monitor CBG q1. At around 5:50 pm, vital signs were stable but CBG is 222mg/dL. Still with bibasal crackles. Patient is on NPO. Shift IVF to D5 0.45NaCl 1L x 100cc/hr. if NA may give D5 0.3 NaCl 1L x 100cc/hr. still for CVP insertion. Laboratory requested were serum Na+, K, Cl, ABGs, PO4, Mg, ECG. Previously ordered labs not carried out were still requested. Insulin drip was continued and medications were continued. Patient is placed on a moderate to high back rest. O2 support at 1-2 lpm via nasal cannula. VS, NVS and CBG monitored q1. WOF hyper/hypoglycemia, changes in sensorium and respiratory distress. On close watch. On the 2nd hospital day, she was still placed on OF feeding with SAP at 500 kcaI IVF to follow: D5 0.45 NSS 1L x 125 cc/ hr. Insulin dri was discontinued new labs requested were ABGs, ketones, calcium, Blood GS/CS x 2 sites. Medications were continued. Regular Insulin was started at 5units subcutaneously for CBG ≥ 250mg/dL. Patient is placed on a moderate to high back rest. VS monitored q1 as well as NVS with strict I and O monitoring and UO. O2 support via nasal canula at 2-3 lpm was maintained. On close watch. At around 6pm, she was still placed on OF feeding with SAP at 500 kcaI IVF to follow: 3 D5 0.45 NSS 1L x 125 cc/ hr. to fast drip on PNSS of about 300cc then regulate to 4 hours meds were contuined. Intermediate Insulin was started at 2 u am and 7 u pm. Medications were continued. Patient is placed on a moderate to high back rest. VS monitored q1 as well as NVS with strict I and O monitoring and UO. CVP guided hydration was continued once materials an consent is completed. O2 support via nasal canula at 2-3 lpm was maintained. WOF hyper/hypoglycemia, changes in sensorium and respiratory distress. On close watch. CVP was regulated to KVO as requested by surgery resident. On the 3rd hospital day, patient has stable vital signs. She was awake, coherent, not in respiratory di146stress. BP 120/80, CR 98, RR 20, T 36. She was maintained on NGT. Medications were secured and continued. Patient was monitored every hour. On the 4th hospital day, patient was awake and coherent. Vital signs were as follows: BP100/70, CR80, RR20, T35 C. CBG is 146 mg/dl, UO 30cc/hr, CVP 18 cm H20. Furosemide 20 mg TIV every 12 hours was started. Other meds were continued. O2 support via nasal cannula at 2-3 lpm was maintained. Watch out for hyper/hypoglycemia, changes in sensorium and respiratory distress. Patient was monitored every hour and is on close watch. Patient was also referred again to endo service. Renal dose of dopamine was started. On the 5th hospital day, patient was awake and coherent. Vital signs were as follows: BP100/60, CR85, RR20, T37 C. CBG is 150 mg/dl, UO 70cc/hr, CVP 14 cm H20. ABG result revealed respiratory acidosis. Patient is negative for ketones. NGT is maintained. Meds were continued. Patient was started on Spironolactone 20 mg tab per NGT BID. Other meds were continued. Monitoring of vital signs, CBG, UO was every hour. Patient was closely watched. On the 6th hospital day, patient was conscious and coherent. Vital signs were as follows: BP100/60, CR78, RR20, T37 C. Patient has bipedal edema and crackles on both lung fields. One unit of PRBC was order to be transferred to the patient. Other meds were continued. Patient was maintained on O2 support via nasal cannula. Monitoring of vital signs, CBG, UO was every hour. Patient was closely watched. At 9:30 pm, patient’s BP dropped to 70/50. Furosemide drip was hold. PNSS was fast dripped to 100 cc. Patient was put on Trendelenburg position. Dopamine drip was increased to 26-27 drops ugtts/min. BP was rechecked after 15 minutes. Patient was referred accordingly. On the 7th hospital day, patient’s vital signs were stable- BP 100/60, CR 78, RR 20. Patient was conscious and coherent. There was still bipedal edema. NGT was maintained. Furosemide drip was resumed. Dopamine drip decreased at 22-23 ugtts/min. Other medications were continued. Patient was maintained on O2 support via ambubagging at 10 lpm. Suction secretion regularly. Patient is on vsq1 monitoring. CBG, CVP and UO monitoring q1. Close watch. Refer accordingly. On the 8th hospital, patient was awake. Vital signs are as follows: BP 90/60, CR 114, RR 22, T 36.8. CVP is 8-9 cm H2O, CBG is 200 mg/dl. NGT is maintained. Furosemide drip was hold. Dopamine drip is continued. CVP guided hydration is continued. Previous medications were continued. O2 support at 10 lpm was continued. Patient was monitored vsq1, CBG q2, CVP q1, UO q1. Refer. On the 9th hospital day, patient was drowsy. BP 90/60, CR 104, RR 20, T 36.9, CVP 8-9 cm H20, clear breath sounds. NGT was maintained. Dopamine drip was continued. Other medications were also continued. Patient was maintained on O2 support via ambubagging at 10 lpm. Suction secretion regularly. Patient is on vsq1 monitoring. CBG, CVP and UO monitoring q1. Close watch. Refer accordingly. On the 10th hospital day, patient was still drowsy. BP 120/80, CR 94, RR 23, T 36.9, CVP 10 cm H20, UO 50 cc. NGT was maintained. Aminoleban 1 sachet was started. Dopamine drip was continued. Other medications were also continued. Patient was maintained on O2 support via ambubagging at 10 lpm. Suction secretion regularly. Patient is on vsq1 monitoring. CBG, CVP and UO monitoring q1. Close watch. Refer accordingly. At 4:30 pm, patient was still drowsy. Vital signs were as follows: BP 130/80, CR 114, RR gasping (34), T 37.6 C. CBG is 300 mg/dl, CVP is 15-16 cm. Patient was then intubated and was hooked to mechanical ventilation. NPO temporarily except meds. VSq1 monitoring. Close watch. On the 11th hospital day, patient was drowsy and intubated. BP 70/40, CR 98, RR assisted, T 36 C. CVP 10 cm, clear breath sounds, flabby abdomen, (+) edema grade II. Present working impressions were sepsis, CAP mild risk, DM 2, s/p BKA, left. Medications were continued. Patient is on vsq1 monitoring. CBG, CVP and UO monitoring q1. Close watch. Refer accordingly. On the 12th hospital day, patient was drowsy. BP 80/60, CR 100, RR assisted, T 35.8. CVP 17 cm, CBG 300 mg/dl. Patient is positive for doll’s eye. Pupils reactive to light, 2-3 mm. NGT was maintained. Dopamine drip was continued. Other medications were also continued. Suction secretion regularly. Patient is on vsq1 monitoring. CBG, CVP and UO monitoring q1. Close watch. Refer accordingly. At 11:15 pm, patient started to have unstable vital signs. BP 0, CR 0, ECG flat II. Patient was tried to be resuscitated. Epinephrine vials TIV were given. Patient expired at 11:50 pm.

LABORATORY RESULTS CBC WITH PC WBC RBC HGB HCT MCV 15 Aug 2007 31.1 x 109/L 3.7 x 1012/L 11.6 mg/dL 33.8 % 90.8 fL 09 Aug 2007 16.2 x 109/L 4.2 x 1012/L 13.0 mg/dL 38.5 % 91.3 fL 08 Aug 2007 8.9 x 109/L 2.6 x 1012/L 9.0 x mg/dL 23.1% 88.2 fL 04 Aug 2007 9.6 x 109/L 3.9 x 1012/L 11.6 x mg/dL 34.9% 88.8 fL

MCH MCHC PLATELET NEUTROPHIL LYMHOCYTES MONOCYTES EOSINOPHILS BASOPHILS

29.5 34.3 168 x 109/L 84 % 14 % 2% 0% 0%

30.9 33.8 165 x 109/L 86.6% 5.4 % 6.4 % 1.6 % 0%

33.8 38.3 215 x 109/L 87.5% 3.7% 7.8% 0.8% 0.2%

29.6 33.3 230 x 109/L 85.3% 6.3% 6.8% 1.1% 0.5%

ROUTINE URINALYSIS (04 Aug 2007) Ketone 3+ (5.0 mmol/L) ROUTINE URINALYSIS (09 Aug 2007) Ketone NEGATIVE BLOOD CHEMISTRY BUN Creatinine Sodium Potassium BLOOD CHEMISTRY Magnesium Phosphorous Potassium Chloride BLOOD CHEMISTRY Triglycerides HDL Glucose Uric acid Cholesterol LDL 04 Aug 2007 4.36 mmol/L 48 umol/L 138 mmol/L 3.5 mmol/L 05 Aug 2007 0.77 mmol/L 0.71 umol/L 3.1 mmol/L 108 mmol/L 05 Aug 2007 0.94 mmol/L 0.80 mmol/L 11.87 mmol/L 0.39 mmol/L 7.23 mmol/L 6.00 mmol/L 08 Aug 2007 2.67 mmol/L 31 umol/L 136 mmol/L 3.1 mmol/L

URINALYSIS (04 Aug 2007) Physical Color: yellow Transparency: clear Microscopic Epith cells: occasional Mucus thread: occasional Amorph urates: occasional Pus cells: 0-2 Erythrocytes: 8-9 Chemical Albumin: (+) Sugar: ( -) Specific gravity: 1.03 pH: 7


				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:30
posted:7/3/2009
language:
pages:5