Salangsang_ Leon PDS by dredwardmark

VIEWS: 218 PAGES: 5

									OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: SALANGSANG, Leon Age/Sex: 60/M Address: Sampaloc, Manila Date of Admission: July 9, 2007 Admitting Diagnosis: CVD Probably Hemorrhagic, Right Hemisphere HCVD, NSR, II – B DM Suspect Final Diagnosis: Residents-in-charge: Drs. Dalanon/Gutierrez/Gregorio Clerks-in-charge: Velasco/Velasco/Viar

Hospital #: Room #: 425 Date of Discharge:

PATIENT DISCHARGE SUMMARY This is a case of a 60-year old male who came in due to left sided body weakness. History of Present Illness Twenty-nine days prior to admission, the patient had left sided body weakness associated with slurring of speech. There was no loss of consciousness, no difficulty of breathing, no seizures, no chest pain. No consultations or medications were done. Five hours prior to admission, the patient was consulted at the ER of this institution. He was advised for Cranial CT scan. Initial findings showed hemorrhage. This prompted the patient for admission. Past Medical History The patient is not known to be hypertensive No DM, no heart disease, no other previous hospitalizations, no operations Family Medical History The patient denies any heredo-familial diseases Personal and Social History Smoker of 10 pack years Occasional alcoholic beverage drinker Review of Systems General: no weight loss, no loss of appetite HEENT: no headache, no blurring of vision, no tinnitus Chest and Lungs: no cough, no colds, no hemoptysis, Cardiac: no orthopnea, no PND, no palpitations GIT: no constipation, no diarrhea Genitourinary: no dysuria, no oliguria, no hematuria Endocrinology: no polyuria, no polyphagia, no polydypsia Nervous: no seizure Hematologic: no easy bruisability Physical Examination General: the patient is awake, and not in cardio-respiratory distress Vital Signs: BP = 180/90 to 160/90mmHg HR = 88 bpm RR = 18 cpm Temp. 37º C Skin: no jaundice, good skin turgor HEENT: anicteric sclerae, pink palpebral conjunctivae, no nasoaural discharge, no tonsilopharyngeal congestion, no cervical lymphadenopathy, no neck vein distention CHEST and LUNGS: symmetrical chest expansion, no retractions, no lagging, clear breath sounds HEART: adynamic precordium, normal rate, regular rhythm, no murmur ABDOMEN: Flat, NABS, soft, non-tender, no organomegaly EXTREMITIES: grossly normal, no cyanosis, no edema Neuro: oriented to time, place, and person CN I- can smell CN II- (+) ROR, can read CN III, IV, VI- intact EOM CN V- (+) corneal reflex CN VII- shallow left nasolabial fold CN VIII- can hear CN IX, X- good gag reflex CN XI- can shrug shoulders R > L CN XII- tongue slightly deviated to the right

Motor 5/5 4/5 5/5 4/5 Assessment:

Sensory 100% 100% 100% 100%

DTR ++ ++ ++ ++

CVD Probably Hemorrhagic, Right Hemisphere HCVD, NSR, II – B DM Suspect

Plan: For admission Course in the Ward Upon admission, patient was maintained on low protein diet with strict aspiration precaution. IVF hooked was PNSS 1L x 12 o. Laboratories requested include: SGPT, SGOT, TB, B1, B2, PT, TPAG, CBC with PC, Blood typing, Alk PO4, Whole Abd UTZ, BUN Crea, Na, K, Cl and possible EGD. Medications prescribed were: Vit K amp TIV q 8 o, Propranolol 10 mg/tab, 1 tab TID and Tramadol 50/amp TIV q8o for pain. Vital signs monitored hourly and CBG at AC/HS. On the 1st hospital day, had 2 bowel movements and had no subjective complaints. Lactulose was given 30 cc at bedtime for bowel movement of 3/day. The patient was monitored every 2 hours and other the standing orders were maintained. On the 2nd hospital day, the patient had 3 bowel movements. His vital signs were as follows: BP=140/90, HR=80, RR=20, T=37 oC. Temporary NPO was advised. Bowel preparation was done for the scheduled ultrasound. On the 3rd hospital day, UTZ was done which showed Liver parenchymal disease, limey bile vs small gallbladder stones, and obscured pancreas. On the 4th hospital day, the patient complained of vomiting, occasional abdominal pain and phlebitis. The patient also had pale palpebral conjunctiva. General liquid diet was discontinued and shift to soft diet was advised. Transfusion of 1 U of PRBC was ordered. Referral to the Department of Surgery regarding cholelithiasis was also ordered. On the 5th hospital day, patient had stable vital signs and had one episode of melena. Management was continued. NGT was inserted and gastric lavage was done. The patient was assessed by the Surgery department and laboratory exams done were PT, PTT, CBC with PC, SGPT, SGOT, ALT. On the 6th day, patient had stable vital signs however, bilous arterial blood was noted in the NGT and gastric lavage was done. On the 7th hospital day, coffee-ground material was found per NGT and there was presence of epigastric pain. Vital signs were stable. Laboratory exams requested were PT, CBC with PC. No bowel movement was noted and lactulose 300 cc was given per NGT until bowel movement of 3-4 times per day was attained. He was started on Famotidine 20 mg TIV every 12 hours. Other medications were continued. On the 8th hospital day, clear lavage was noted per NGT and patient had stale vital signs. NGT was removed and patient was placed on general liquid diet. Patient was started on Sucralfate 2 g TID PO. On the 9th hospital day, patient had stable vital signs and no subjective complaints. Patient was brought to the radiology department for HBT ultrasound with initial reading of liver parenchymal disease and limey bile. He was referred back to surgery for re-evaluation. On the 10th hospital day, patient was stable and with no subjective complaints. Management was continued. On the 11th hospital day, patient’s vital signs were stable. Patient complained of abdominal pain, bloatedness, vomiting of previously-ingested food, melena, and hematochezia. DRE results noted fresh blood. Patient was placed NPO and NGT was reinserted. On the 12th hospital day, coffee ground material was found in the NGT. Famotidine was shifted to Omeprazole 40 mg TIV OD and other medications were continued. On the 13th hospital day, coffee-ground material seen per NGT. He was transfused with one unit pRBC with follow-up CBC. On the 14th hospital day, patient had stable vital signs and clear NGT aspirate but complained of crampy abdominal pain. Buscopan was given one ampule. Present management was continued. On the 15h hospital day, vital signs were stable but patient reported hematochezia. Management was continued with addition of stool charting. Tranexamic acid was prescribed for active bleeding 500 mg TIV every 8 hours. On the 16th hospital day, patient had melena. Red stool was noted upon digital rectal exam. Present management was continued. On the 17th hospital day, coffee-ground material was noted per NGT, with melena, and red stool upon DRE. Other medications were continued. On the 18th hospital day, coffee-ground material was seen on NGT, fresh blood noted upon DRE. Patient had stable vital signs. Patient was started on Somatostatin 250 mg TIV then Somatostatin drip (3g in D5W). Other medications were continued. On the 19th hospital day, coffee-ground material was seen on NGT and fresh blood noted on DRE. Somatostain drip was continued and epinephrine was done every 6 hours. CBC with PC was done. On the 20th to 22nd hospital day, coffee-ground material was still present, current management was continued. On the 23 rd hospital day, Patient’s vital signs were BP 120/80 CR 60 RR 18 Temp 36.4 degrees. Patient still has pale Palpebral conjunctiva, and icteric sclera, epigastric pain. DRE revealed dark red colored stool. Patient was continued on somatostatin drip. Around 5:00 p.m. patient was referred to Dr. Lucero who performed EGD. Result were (1) severe esopaghitis grade D (2) blood pooling at the stomach (3) active bleeding of ampullary mass 2-3 cm. Biopsy taken. Somatostatin drip and NGT was discontinued, but Epinephrine wash was continued. Patient was recommended for surgery referral for the management of bleeding of ampullary mass. On the 24th hospital day vital signs were BP: 140/90 CR 60 RR 16 Temp 36.5 degrees. Still with epigastric pain and black colored stool, icteric sclera and pale Palpebral conjunctiva.No difficulty of breathing. Patient was referred to Dr. Mujer for further management of bleeding ampullary mass. On the 25th hospital day patient’s vital signs were BP 110/50 RR 20 CR Temp 37.1 degrees. Patient complains of abdominal pain crampy in character. He had 3 episodes of vomiting of coffee-ground material. CBG as of 10 am is 80 mg/dl. Around 11 pm patient was seen by Dr. Mujer surgery noted pending management upon retrieval of final histopath due to extremely difficult treatment option benign and malignant lesion. Other diversional endoscopic or percutaneous option are still open; definitive surgery if malignant. May suggestCT scan of the abdomen with contrast while waiting for histopath result. On the 26th hospital day, surgery notes was appreciated. Patient vital signs were BP 120/80, CR 61, RR 19, temp 36.4 degrees. Patient still has icteric sclera, pink palpebral conjunctiva. No abdominal pain, no nausea, no vomiting, no bowel movemnet as of 10 am today. No change in sensorium. No other subjective findings. No signs of active bleeding. Around 9:30 pm serum potassium result was noted to have 2.4, IVF fluid is revised to PNSS 1L + 40 meqs KCl to run for 6 hours. 12 lead ECG was done. On the 27th hospital day patient’s vital signs were BP 110/60, CR 80, RR 19, Temp 37 degrees. Patient complains of occasional abdominal pain. Had 2 episode of bowel movement, noted black stool. Patient still has icteric sclera, pink palpebral conjunctiva, noted black stool on DRE.

On the 28th hospital day, he vomited approximately 1 glass of black vomitus. NGT was immediately inserted. Gastric lavage was done every 6 hours, as well as epinephrine swallow every 8 hours. He was watched out for signs of active bleeding, hypotension, hypoglycemia, and changes in sensorium. He was referred to surgery for the definitive management of persistent bleeding and possible transfer of service. The following medications were started: tranexamic acid 500mg / 5 ml amp TIV q 8, omeprazole 40 mg IV OD, Sucralfate 1 g q 6 PO, and Vitamin K ampule TIV q 8. vital signs and neuro vital signs were monitored every hour, as well as CBG every 2 hours. On the 29th hospital day, vital signs were stable. 1 unit of PRBC properly typed and crossmatched was transfused which run for 4 hours. Post BT CBC was done. Still for 1 unit of fresh whole blood, properly typed and crossmatched. Still for whole abdomen CT scan. Surgery suggested Argon Plasma Coagulation for the management of the bleeding periampullary mass, but the hospital doesn’t have the facility to facilitate the said procedure. On the 30th hospital day, the patient’s vital signs were stable (BP = 130/80, CR = 85, RR = 20, T = 37). The NGT was maintained on the patient. Still to secure 1 unit of fresh whole blood properly typed and crossmatched. Medications were continued. He was maintained on moderate to high back rest, with vital signs and neuro vital signs monitored every hour, as well as CBG every two hours. He was also watched out for signs of hypoglycemia, difficulty of breathing, and signs of active bleeding. On the 31st hospital day, patient vital signs were: BP=130/80, CR=90, RR=20, T=26. Still with coffee ground fluid per NGT. He had no abdominal pain and chest pain. NGT is maintained with gastric lavage every 6 hours. Still for 1 unit of fresh whole blood properly typed and crossmatched. Other previous management was continued. At 5:00 PM whole abdominal CT scan with contrast was done. On the 32nd hospital day, the patient still produce coffee ground per NGT approximately 200ml per lavage. Melena also persisted. Previous management was continued. Repeat serum K, and Protime were requested and carried out. On the 33rd to 35th hospital day, patient vital signs were stable (BP=110/80, CR=80, RR=18). Official CT scan result of the whole abdomen was released. Present Working Impression became: UGIB secondary to Periampullary mass, Periampullary or Peripancreatic or Pancreatic Head Mass. The results were referred to Surgery and recommended continuation of present management. Still for official Histopathology result. On the 36th to 38th hospital day, the patient complained abdominal pain, epigastric in location, non-colicky and non-radiating. BP=100/70, CR=84, RR=21, T=37. Previous management and medications were continued. On the 39th hospital day (July 6), the patient still complains with abdominal pain, with occasional cough, and fever. BP=100/70, CR=117, RR=28, T=39.5. PE of the lungs revealed crackles bibasal, with direct abdominal tenderness on the left lower quadrant, and with grade 1 pitting edema of both legs. Bedsore precaution was also ordered, where the patient is advised to be turned side to side every 2 hours. Repeat urinalysis and chest x-ray were requested. Final histopathology findings revealed Focal Glandular Dysplasia. The patient was referred back to surgery department with the results. Surgery suggested options considering the physical status of the patient to withstand traditional pancreaticoduodenectomy: 1. Endoscopic Ablative Therapy, and 2. Endoscopic Transduodenal Expansion. The said options have successful or favorable morbidity ratio / success ratio compared to the traditional surgery. The department was suggesting for transfer of the patient to an institution available for such options. On the 39th hospital day, patient’s blood pressure dropped to 90/60 – 70/50. Immediate transfusion of 1 unit of PRBC property typed and crossmatched was done. One to two hours post transfusion, the patient’s vital signs became stable, BP=110/70, CR=80, RR=20, T=36.6. No blood transfusion reactions were noted. Present management was continued. On the 40th hospital day, the patient still complains of occasional abdominal pain, epigastric in location, non-radiating. He also complained of dysuria. Still with grade 1 bipedal edema. Further evaluation revealed tender abdomen lower quadrants. Present working impression was UGIB secondary to periampullary mass - pancreatic mass, UTI complicated. Cirpofloxacin 500mg tab BID through NGT was included in the medications. Still with coffee ground fluid per NGT approximately 200ml per gastric lavage. Other previous management continued. On the 41st hospital day, the patient was noted to have petechial rashes, both upper extremities, no fever, still with occasional abdominal pain. BP=90/60, CR=85, RR=20, T=37.4. Still with direct abdominal tenderness, and grade 1 bipedal edema. Previous management continued. On the 42nd hospital day (July 10), the patient was still with the above condition. Repeat PT, and serum Na, K were ordered. Still for 2 units of PRBC properly typed and crossmatched. Previous management continued. On the 43rd hospital day (July 11), BP=140/90, CR=66, RR=21, T=36.5. Gabapentin or pregabalin given if patient will experience paresthesia or pain on the involved extremities. Previous management continued. Vital signs monitored every 2 hours. On the 44th hospital day (July 12), BP=140/80, CR=80, RR=20, T=36.8. Motor: Left Upper and Lower Extremities: (3/5) Right Upper and Lower Extremities: (5/5). Previous management continued. Vital signs monitored every 2 hours. On the 45th hospital day (July 13), BP=150/100, CR=78, RR=20. Previous management continued. Vital signs monitored every 2 hours, cardiac rate and respiratory rate taken at a full minute, CBG taken AC/HS. On the 46th hospital day (July 14), BP=140/90, CR=80, RR=20, T=36.8. Motor: Left Upper and Lower Extremities: (5/5) Right Upper and Lower Extremities: (5/5). Previous management continued. Vital signs monitored every 2 hours, cardiac rate and respiratory rate taken at a full minute, CBG taken AC/HS. On the 47th hospital day (July 15), BP=140/90, CR=70, RR=18, T=37. Patient is conscious and coherent. Motor: Left Upper and Lower Extremities: (5/5) Right Upper and Lower Extremities: (5/5), DTR (both left and right/upper and lower extremities): +2. Previous management continued. Mannitol was given as follows: 100cc every 12hours x 2 doses then 100cc OD, then was discontinued. Vital signs monitored every 2 hours, cardiac rate and respiratory rate taken at a full minute, CBG taken AC/HS. On the 48th hospital day (July 15), BP=130/80, CR=75, RR=18, T=37. Patient is conscious and coherent. Motor: Left Upper and Lower Extremities: (5/5) Right Upper and Lower Extremities: (5/5). Patient was advised to go home and come back after a week for a follow up check-up. Home medications: Imidapril + HCTZ 10mg/12.5mg tab, 1 tab OD; Captopril 25mg tab prn for BP > 160/90, SL; Sucralfate 1gm/tab every 6 hours; Citicholine 100g/ml, 2ml TID. Laboratory Results:

Blood Typing ABO: B RH: positive Hematology Prothrombin time Normal Values 11-14 s May 29, 2007 13.5 June 17, 2007 13.1 June 27, 2007 15.9 July 6 17.6

% Activity INR Control Slide or Drop Duke Method

11.5-15.5 secs 2 – 4 min 1 – 3 min

86% 1.07 14

92.5 % 1.01

66.1 1.29 5 min 15 secs 2 mins

55.4 1.46

Complete Blood Count Normal Values WBC RBC Hgb Hct MCV MCH MCHC Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils 4.8-10.8 x 109 /L 4.0-6.20 x 1012 /L 1216g/dl 37-47 % 80-90 fL 27-31 32-36 150-400 x 10^9/L 55-57 20-30% 0-7% 0-3% 0-1%

May 29, 2007 10.9 3.1 9 27.9 89.1 29.9 34 601 72 18 8 2 0

June 6, 2007 12.9 3.3 9.1 28 85.1 27.6 32.4 540 68.5 26.9 3.5 1.1 0

June 9, 2007 9.2 3.0 8.2 25.0 83.6 27.5 32.9 491 77 22 1

June 11, 2007 9.7 3.1 9.0 26.0 83.4 28.3 33.9 534 75.6 16 6.1 2.3 0

June 13, 2007 10.5 3.0 8.5 25.1 84.4 28.5 34 574 89.1 6.7 3.1 1 0.1

June 16, 2007 7.9 3.3 9.5 27.7 83.6 28.6 34 435 77.7 19.9 1.5 0.9 0

June 17, 2007 8.5 3.4 9.7 28.8 84.3 28.3 34 426 80.4 13.8 4.2 1.4 0.2

June 18, 2007 7.9 4.0 11.7 33.9 84.1 28.9 34 295 91.3 7.4 0.7 0.5 0.1

June 23, 2007 9.1 3.5 9.7 29.2 83.4 27.6 33.1 214 78.4 17.5 3 1.1 0

June 25, 2007 6.4 4.2 11.6 35 83.9 27.8 33.1

June 28, 2007 8.4 3.7 10.1 30.8 84.3 27.6 33 300 56.3 40.1 1.9 1.7 0

June 30 5.3 2.6 7.3 21.5 83.8 28.4 34 256 82.5 14.1 1.3 2 0.1

July 7 13 2.5 7.3 21.3 84.5 28.8 34 152 46.8 52.2 0.4 0/6 0

71 29

Hepatitis Profile Test HBs Ag Anti-HAV IgM Anti-HCV Note: Icteric specimen Urinalysis Color Transparency Epithelial Cells Mucus Threads Amorphus Urates Pus Cells Erythrocytes Albumin Sugar SG pH Calcium Oxalate

Result Non-reactive Non-reactive Non-reactive

Patient’s Count 0.050 0.087 0.079

Cut-Off Value 0.097 0.180 0.214

May 29, 2007 Yellow Clear Occasional Few Occasional 0-2 0-1 none Trace 1.020 6.0

July 7 Dark yellow Slightly turbid Few Few Few 6–8 0–1 1.015 6.0 many

Blood Chemistry Normal Values 2.5 - 7.10 mmol/L 53 – 115 umol/L 10-34 U/L 9-43 U/L 100-290 U/L 62-80 g/L 38-51 g/L 24-29 U/L 1.30-3 135-145 mmol/L June 1, 2007 6.16 84.43 143.89 98.23 888.89 58.37 28.14 30.23 0.93:1 135.90 June 19, 2007 June 23, 2007 June 25, 2007 June 28, 2007 July 1, 2007 July 8 9.16 204

BUN Creatinine SGOT SGPT Alkaline Phosphatase Total Protein Albumin Globulin A/G Ratio Sodium

12

166

167

Potassium Chloride Glucose Cholesterol Triglyceride HDL LDL HbA1C Total Bilirubin Direct Bilirubin Indirect Bilirubin

3.40-5.30 mmol/L 98.0-107.0 mmol/L 3.90 – 6.10 mmol/L 5.20 – 6.20 mmol/L 0.34 – 1.70 mmol/L 0.91 – 1.56 mmol/L 1.10 – 3.80 mmol/L 4.27-6.07 % <17.00 umol/L <5.10 umol/L <11.90 umol/L

3.55 103.90

2.7 121

2.4

2.9

2.7

2.2

2.0

283.69 148.20 135.49

Radiologic Study 1. HBT Ultrasound (June 1, 2007) – Liver Parenchymal Disease, Limey Bile


								
To top