millano 4 printing by dredwardmark

VIEWS: 2 PAGES: 2

									Ospital ng Maynila Medical Center Department of Internal Medicine

Name: Millona, Seralina Age/Sex: 66/F Address: Brgy. 713 Leveriza Malate Manila Date of Admission: July 3, 2007 Admitting diagnosis: Uncal herniation probably secondary to CVD hemorrhage, HCVD, NSR II B S/P arrest 3x Residents in charge: Drs. Gonzales/Filio/Indon

Hospital #: 1705314 Room #: 424 Date of Death: July 4, 2007 Final Diagnosis: Uncal herniation
probably secondary to CVD hemorrhage, HCVD, NSR II B S/P arrest 3x

CIC: Villanueva/Villarama/Ybanez

DEATH PROTOCOL

This is a case of a 66 year old female who was brought in due to loss of consciousness. History of Present Illness One hour prior to admission patient complains of headache and nape pain, not associated with blurring of vision, vomiting and fever. No consult or medications was done. 30 minutes prior to admission, patient had sudden onset of loss of consciousness after seeing a family member with bleeding forehead. Persistence of symptoms prompted consult and hence subsequent admission. Past Medical History Not known hypertensive No previous hospitalization No allergies Family History Denies heredofamilial diseases Personal and Social History Non-smoker, non-alcoholic beverage drinker Review of Systems General: no weight loss, no anorexia HEENT: no headache, no blurring of vision, no epistaxis, no tinnitus Cardiovascular: no chest pain, no palpitations, no DOB Gastrointestinal: no abdominal pain, no change in bowel habit, no diarrhea, no melena Genitourinary: no dysuria, no hematuria, no oliguria Hematologic: no easy bruisability Endocrine: No polyuria, no polydipsia, no polyphagia Physical Examination: On admission patient was comatose, intubated on continuous ambubagging Vital Signs: BP 30 palpatory HR: 62 faint RR: non spontaneous, assisted Temp: 36.7oC SKIN: no pallor HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathy, no neck vein distention CHEST AND LUNGS: symmetric chest expansion, no retractions, no crackles HEART: adynamic precordium, PMI at 5th ICS LMCL, normal rate regular rhythm, weak heart beat, no murmur ABDOMEN: flabby, normoactive bowel sounds, soft, nontender, EXTREMITIES: grossly normal, cold clammy extremities, no cyanosis

NEURO: COMATOSE GCS: M1V1E1 CN I: N/A CN II: Fixed dilated CN III, IV, VI: (-) doll’s eyes CN V: (-) bicorneal reflex CN VII: N/A

CN VIII: N/A CN IX, X: no gag CN X!: N/A CN XII: N/A SENSORY (-) WTP (-) WTP DTR MOTOR + 0/5 0/5

+

(-) WTP

(-) WTP

+

+

0/5

0/5

ASSESSMENT: Uncal herniation probably secondary to CVD hemorrhage, HCVD, NSR II B S/P arrest 3x

COURSE IN THE WARDS: Upon arriving at the Emergency Room, patient was assessed. diagnostic tests such as Chest X-ray PA, CBC with PC, 12 lead ECG and urinalysis were done. Maintain on NGT, placed on NPO. Patient was given Citicholine 5mg to IV every 8 hours.Patient was intubated and was put on mechanical ventilation to provide O2 support with TV-400 cc, FW –IW, RR-18. Consent for DNR was noted. On the first hospital day ,patient’s vital signs around 9:55 am were BP 70 palpatory, RR assisted, CR 78, Temp 35.9 degrees. Patient is still comatose. Patient was hooked on Dopamine drip. Around 11:00 am patient’s vital signs were BP 0, CR 0, ECG flat, pupils were dilated. Around 11:05 am patient’s vital signs were BP 0, CR 0, ECG flat, pupils were dilated. Around 11:10 am patient’s vital signs were BP 0, CR 0, ECG flat, pupils were dilated. Patient was pronounced dead.

Laboratory Results:
Urinalysis Color Transparency Epithelial Cells Mucus thread Amorph. Urates Pus cells Erythrocytes Albumin Sugar Sp. Gravity pH Amorhp phosphate July 3, 2007 Yellow Clear Few Few 1-2 6-9 +3 Trace 1.020 7.0 few

CBC with PC
WBC RBC HGB HCT MCV MCH MCHC Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils July 3,2007 12.5 4.2 10.0 30.2 72.6 24.1 33 174 79.1 15 2.3 3.3 0.3


								
To top