OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: SALESTIANO, ANGELINA Hospital #: 1797032 Age/Sex: 75/F Address: 285 Tahimik Cor. CM Recto St. Tondo, Manila Date of Admission: Feb. 2, 2008 Admitting Diagnosis: CVD prob. Infarct prob. Cardioembolic HCVD, LVH, AF with MVR, NIF CKD St. V 2° Hypertensive nephrosclerosis HAP Final Diagnosis: UNcal herniation 2° CVD prob. Cardioembolic with hemodynamic conversion Residents-in-charge: Drs. Filio/Indon/Cruz
DEATH PROTOCOL This is a case of a 75 year old female who came in due to loss of consciousness. HISTORY OF PRESENT ILLNESS 10 days prior to admission, the patient was found on the floor with decreased responsiveness and right sided body weakness. The patient was then brought to JP Rizal Hospital and was admitted for 9 days with a diagnosis of CVD, ARF prob. 2° ATN, CKD 2° hypertensice nephrosclerosis vs chronic glomerulonephritis.Medications given were Citicholine 500mg 1 amp BID, Mannitol 100cc q4, and NaHCO3. Pesistence of the above symptoms prompted transfer in this institution. PAST MEDICAL HISTORY (+)HPN- maintained on Felodipine but is noncompliant S/P CVD 2000 No asthma, allergy and heart disease. FAMILY HISTORY (+) HPN- siblings No family history of Asthma, heart disease and thyroid diseases. PERSONAL/SOCIAL HISTORY Nonsmoker and non-alcoholic beverage drinker. Denies illicit drug use. REVIEW OF SYSTEMS: Constitutional: No anorexia or weight loss. HEENT: No blurring of vision. No tinnitus Integument: No rashes. No pruritus. Hair: No hair loss. Gastrointestinal sytem: No nausea and vomiting. No abdominal pain, no change in bowel movement. Cardiovascular system: No orthopnea. No PND. No easy fatigability. Genitourinary system: No dysuria. No gross hematuria. No incontinence and urinary retention. No genital pruritus. Neuromuscular: No pain. No stiffness. No seizures, tremors, convulsions. Hematopoeitic sytem: No easy bruising. No gum bleeding, epistaxis. No melena. No observed prolonged bleeding. No hematemesis. Endocrine system: No heat and cold intolerance. No sluggishness, hoarseness. No polyuria, polydipsia and polyphagia.
PHYSICAL EXAMINATION General: stuporous to comatose, intubated Vital Signs: BP: palpatory 60 HR: 105 RR: assisted SHEENT: Anicteric sclerae, pink palpebral conjunctivae, No Nasoaural Cervicolymphadenopathy Chest and Lungs: symmetrical chest expansion, No retractions, clear breath sounds Heart: Adynamic precordium, Normal rate, regular rhythm, no murmur. Abdomen: Flat, Normoactive bowel sounds, soft, non tender on palpation. Extremities: Grossly normal, No edema, no cyanosis. Neurologic: Mental Status Exam: stuporous to comatose CRANIAL NERVES: I – N/A. II - Pupils are equally reactive to light and accomodation III, IV, VI – (+) Doll’s eye V – (+) Bicorneal Reflex. VII – (-) asymmetry VIII – N/A IX, X – weak gag. XI – N/A XII – N/A
Temp: 37.7 C discharge, No
(+) Babinsky. right (-) Nuchal rigidity ASSESSMENT: PLAN: CVD prob. Infarct prob. Cardioembolic
HCVD, LVH, AF with MVR, NIF CKD St. V 2° Hypertensive nephrosclerosis HAP
Upon admission, I and O monitoring was done and NGT was maintained. He was hooked on PNSS 1L x 12. Laboratories done were CXR PA, CBC,PC,and ABG. Medications given: patient was started on Mannitol 100cc q6, NaHCO3 tab 1 tab TID/NGT, FeSO4 tab 1 tab TID/NGT, and Pip-tazo 2.35gm q8 ANST. The patient was hooked to mechanical ventilation with the ff. set-up: F1O2 100%, TV 360cc , and RR 16. Patient was maintained on a high back rest. Vital signs and Neurovital signs were monitored every 1 hour. At 8:10 pm, patient was referred to the resident on duty for BP=0 and HR=0. CPR was started, ECG LLII was done. Epinephrine 1amp was given. Vital signs were monitored q15min. At 8:15 pm BP=0, CR=0 RR=0. CPR was continued. ECG LLII was done. Epinephrine 1amp was given. Vital signs were monitored q15min. At 8:20 pm BP=0, CR=0 RR=0. CPR was continued. ECG LLII was done. Epinephrine 1amp was given. Vital signs were monitored q15min. At 8:25 pm BP=0, CR=0 RR=0. CPR was continued. ECG LLII was done. Epinephrine 1amp was given. Vital signs were monitored q15min. At 8:30 pm BP=0, CR=0 RR=0. CPR was continued. ECG LLII was done. Epinephrine 1amp was given. Vital signs were monitored q15min. At 8:35 pm BP=0, CR=0 RR=0. CPR was continued. ECG LLII was done. Epinephrine 1amp was given. Vital signs were monitored q15min. At 8:40 pm BP=0, CR=0 RR=0, pupils fixed dilated. Patient was pronounced dead and postmortem care was facilitated.
SUMMARY OF LABS: Normal Values 9 4.8-10.8 x 10 /L 12 4.0-6.20 x 10 /L 12-16g/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% Feb. 2 16.5 3.62 10.6 35.5 98 29.4 30 210 95.8 2.8 1.4
WBC RBC Hgb Hct MCV MCH MCHC Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils ABG Parameter pH pCO2 pO2 HCO3 TCO2 Beb O2St
Feb.2 7.307 11.70 mmHg 202.00 mmHg 5.90 mmol/L 6.20 mmol/L -16.5 mmol/L 99.70
Cause of death: UNcal herniation 2° CVD prob. Cardioembolic with hemodynamic conversion