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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Dela Peña, Ponciana Hospital #: 1685848 Age/Sex: 65/F Room #: 401 Address: 93 Tanque St., Paco, Manila Date of Admission: May 12, 2007 Date of death: May 15,2007 (10:55 pm) Admitting Diagnosis: Community Acquired Pneumonia, High Risk Final Diagnosis: Refractory Septic Shock Secondary to Pneumonia, High Risk, PTB III Residents-in-charge: Drs. Delos Reyes/Estrada Intern-in-charge. Charise Benederio Clerks-in-charge: Tiglao/Tuble/Vasquez

DEATH PROTOCOL This is a case of a 65 year old female who came in due to difficulty of breathing. History of Present Illness Patient had fever having on and off cough for 9 months, One week prior to admission, patient started to have cough, productive of yellowish phlegm, with no difficulty f breathing and no fever. No medications were taken, no consult was done. Two days prior to admission, signs and symptoms persisted, now with associated fever, undocumented and dyspnea. No consult was done, and no medications were taken. Few hours prior to admission, there was increased in severity of dyspnea which prompted consult at our institution, hence this admission. Past Medical History (-) PTB, DM, HPN, CA, BA Family History Denies of any heredofamilial diseases. Personal/Social History Non-smoker Non alcoholic beverage drinker Review of Systems General: (+) weight loss HEENT: no tinnitus, no blurring of vision, no headache Cardiovascular: no chest pain, no PND, no orthopnea GIT: no abdominal pain, no diarrhea, no constipation GUT: no dysuria, no hematuria, no oligurian no frequency Endocrine: no polyuria, no polydipsia, with polyphagia Neurologic: no changes in sensorium, no loss of consciousness, no seizure Physical Examination: Patient is conscious, coherent, cachexic and in respiratory distress. o BP: 60 palpatory HR: weak RR: Assisted Temp: 38. 5 C HEENT: anicteric sclerae, pink palpebral conjuctiva, mass on the right temporal area, no naso-aural discharge, no cervical lymphadenopathies Chest and Lungs: Symmetric chest expansion, (+) retractions, decreased breath sounds on right lung, increased fremitus on right, (+) egophony (+)diffuse crackles on both sides Heart: Adynamic precordium, tachycardic, weak heart rate, no murmurs Abdomen: flabby, normoactive bowel sounds, soft, non tender Extremities: grossly normal, full and equal pulses

Final Diagnosis: Refractory Septic Shock Secondary to Pneumonia, High Risk, PTB III Patient admitted at room 407 under the service of Dr. Estrada and Dr delos Reyes. Upon admission the patient was initially placed on NPO. IV fluid was inserted using D5W 1L to run for eight hours. The following works up done: CBC with platelet count, urinalysis, CXR-PA, ECG, ABGs, Sputum AFB x 3, Sputum GS/CS, Blood CS x 2 sites, BUN, Creatinine, Na, K, SGPT, SGOT Sputum GS/CS, Blood CS x 2 sites.. Patient started with following medications: Co-Amoxiclav 1.2 g TIV every 8 hours ANST, INH + Rifampicin + Ethambutol + Pyrazinamide (Myrin P forte) 3 tabs once a day before breakfast, Salbutamol nebulizations every 4 hours Paracetamol 300 mg thru IV prn. Patient was hooked to oxygen via nasal cannula at 6 lpm. Vital signs monitoring every hour. Patient should be watched out for respiratory distress.

On the First Hospitalization day (May 13, 200) . The patient is conscious, coherent, cachexic, in respiratory distress. The patient is hypotensive with fluctuating blood pressure of less than 90mmHg. IV line with PNSSfast drip was placed The patient was referred to surgery department for CVP line insertion for hydration. CVP initial reading of 11-12cm H2O. Dopamine drip of 18-19 ugtt/min was ran. NGT feeding was also started with 1750 kcal. She was intubated and hooked to an ambu bag at 10 Lper minute. She was maintained with the following medicatipons: : Piperacillin Tazobactam 2.75 mg thru IV every 8 hours, INH + Rifampicin + Ethambutol + Pyrazinamide (Myrin P forte) 3 tabs once a day before breakfast, Salbutamol nebulizations every 4 hours Paracetamol 300 mg thru IV prn Diagnostics requested were , ECG, ABGs, Sputum AFB x 3, Sputum GS/CS, Blood CS x 2 sites. On the second Hospital day (May 14, 2007). The patient is cyanotic, tachyccardic and hypotensive with fluctuating blood pressures less than 90 mm Hg. She had a diffuse crackles on both lung field. She was maintained with the following: NGT and continued feeding with 1750 kcal, IV line in the Left arm PNSS 1L every 8 hours and PNSS 1L to keep vein open . CVP guide hydration. Due to persistent hpyoptension, Dopamine Drip was increased from 26-27 ugtt/min (7mkd) to 37-38 ugtt every minute . Intubated with ventilation to an ambu bag at 100 lpm. . Continue guided CVP hydration. Suction secretion was done every hour. Maintained in T- position with mild to moderate back rest. Vital signs monitoring and CVP measurement every 30 minute. She was also maintained with the following medicatipons: Piperacillin Tazobactam 2.75 mg thru IV every 8 hours, INH + Rifampicin + Ethambutol + Pyrazinamide (Myrin P forte) 3 tabs once a day before breakfast, Salbutamol nebulizations every 4 hours Paracetamol 500 mg (1 ½ cap of 300 mg) thru IV prn Diagnostics requested were the following: ECG, ABGs, Sputum AFB x 3, Sputum GS/CS, Blood CS x 2 sites. On the third Hospital Day (May 15, 2007). The patient is cyanotic, tachyccardic and hypotensive with blood pressure of less than 60 H20 palpatory. She was maintained in a Tredelenberg position. Urine output is less than 30 cc/hour. She was maintained with the following: NGT and Continued feeding with 1750 kcal, IV line in the Left arm PNSS 1L every 8 hours and PNSS 1L to keep vein open . CVP guide hydration. Due to persistent hypotension, Dopamine Drip was increased from 45-46 ugtt per minute to 56 minute. Intubated with ventilation to an ambu bag at 10 lpm. . Continue guided CVP hydration. Suction secretion was done every 30 minutes . Maintained in T- position with mild to moderate back rest. Vital signs monitoring and CVP measurement every 30 minute. Diagnostics requested were , ECG, ABGs, Sputum AFB x 3, Sputum GS/CS, Blood CS x 2 sites Maintainance medication was given which are as follows: Piperacillin Tazobactam 2.75 mg thru IV every 8 hours, INH + Rifampicin + Ethambutol + Pyrazinamide (Myrin P forte) 3 tabs once a day before breakfast, Salbutamol nebulizations every 4 hours Paracetamol 300 mg thru IV prn The patient went into cardiopulmonary arrest and was resuscitated. The patient was given 1 ampule of epinephrine every 5 minutes and Noradrenaline (Levophed) drip 55 ugtt/ minute. 11 lead ECG was done. ECG result was flat. Pupils size is 4mm. fixed, nonreactive to light. However the patient was proounced dead. Post mortem care was done


				
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