MORBIDITY & MORTALITY MORBIDITY & MORTALITY CONFERENCECONFERENCE

FEBRUARY 2010FEBRUARY 2010

Presentors: Liza D. Mariposque, M.D. Philip March Alquizar, M.D.Marie Micheau Conference Room

February, 2011

Perpetual Succour HospitalDepartment of Family & Community Medicine

TOTAL HOSPITAL ADMISSIONSTOTAL HOSPITAL ADMISSIONS 1,2131,213

Internal Medicine 577 (47.57%)

Pediatrics 215 (17.72%)

Family Medicine 148 (12.20%)

Obstetrics and Gynecology 138 (11.38%)

Surgery 135 (11.13%)

Admissions : 148

OPD:

PSH : 273

Community : 14

House Case : 9

Co-managed : 44

Charity : 2

Mortality : 2

FAMILY MEDICINE

Family Medicine CasesFamily Medicine Cases

Adult Medicine 78 (68.42%)Pediatrics 24 (21.05%)Surgery 9 (7.90%)OB & GYN 3 (2.63%)

FAMED LEADING CAUSES OF FAMED LEADING CAUSES OF MORBIDITIESMORBIDITIES

ADULT: Community Acquired Pneumonia Urinary Tract Infection Acute Gastroenteritis

HEENT 9Upper Respiratory Tract Infection 1

Sinusitis 4

Maxillary, Bilateral

w/ Acute Bronchitis ………..….1

w/ DM 2 ……………1

Acute Tonsillitis 4

w/ Dyslipidemia ……………1

w/ HPN ……………1

78(68.42%)78(68.42%)ADULT MEDICINE

CARDIOVASCULAR SYSTEM 12

Hypertensive Urgency 4©w/ CAP-MR; …………………………1

Lichen Simplex Chronicus (toes);

Cholelithiasis; Uterine Myoma;

Chronic Venous Insufficiency; HCVD

w/ Dyslipidemia, UTI …………………..1

Hypertension Stage II 3

w/ Error of Refraction ……………1

w/ Hypertensive Nephrosclerosis,

w/ Maxillary Sinusitis ..……1

w/ DM2 ………………………….1

Dilated Cardiomyopathy 1

2ndary to HCVD, DM2,

w/ Viral Epidemic Keratoconjunctivitis

Chronic Stable Angina 1

w/ CAD, DM2, Colonic Polyp ………1

S/P Colonoscopy 2/11

Congestive Heart Failure 2

FC-II,HCVD, DM2 …………………1

FC-III, CD-AF w/ MVR; CAP-MR,

HCVD,CAD, DM2, DVI…………..1

Ŧ Probable Aortic Dissection, 1

Proximal Aorta, HCVD, DM 2

INTERNAL MEDICINEINTERNAL MEDICINERESPIRATORY SYSTEM 12

Acute Bronchitis 2Pulmonary Tuberculosis 1

Class III w/ DM Type 2

Chronic Obstructive Pulmonary Disease 1

in Acute Exacerbation

w/ Ulcer-like-Dyspepsia

Community Acquired Pneumonia 8Low Risk 2

w/ Asthmatic Component ……1

CAP - Moderate Risk 6w/ DM 2, Uncontrolled ……………….….1w/ HCVD, DM2, Dyslipidemia ……………….1w/ CKD 2ndary to HPN Nephrosclerosis,

HCVD …………………………………..….1w/ Maxillary & Ethmoidal Sinusitis ………1

w/ Lumbosacral Radiculopathy probably

2ndary to TB/Malignancy; Internal Hemorrhoids; Cholelithiasis

……………..1

INTERNAL MEDICINEINTERNAL MEDICINE

GASTROINTESTINAL SYSTEM 5

Cholelithiasis 1

Chronic Liver Disease 1

2ndary to Schistosomiasis,

w/ Hypersplenism 2ndary to

Schistosomiasis …………………1

Decompensated Liver Cirrhosis© 1

2ndary to Chronic Hepatitis B Infection

Upper GI Bleeding 1

2ndary to Erosive Gastritis

w/ CKD 2ndary to

HPN Nephrosclerosis; HCVD;

CD-AF w/ MVR …………………….1

Adenocarcinoma, Rectosigmoid© 1

Anemia 2ndary to # 1

S/P Colonoscopy 2/21

INTERNAL MEDICINEINTERNAL MEDICINEGENITO-URINARY SYSTEM 10

Urinary Tract Infection 7w/ Non-Ulcer Dyspepsia ……..1w/ Rhinosinusitis …………………...1w/ Essenntial HPN …………………...1w/ HPN & Dyslipidemia…………….1

Acute Pyelonephritis 1Ureterolithiasis, L 2

MUSCULOSKELETAL SYSTEM 1

MUSCULOSKELETAL SPASM1

SKIN1

Cellulitis, R foot1

w/ UTI

RHEUMATOLOGYRHEUMATOLOGY 2 2

Acute Gouty Arthritis 2

S/P Arthrocentesis ………………………1

CKD 2ndary to Urate Nephrolithiasis,

w/ Indirect Hernia, L ………………..1

ONCOLOGYONCOLOGY 2 2

Breast Carcinoma 1

Stage II-B, S/P Chemotherapy 8th Cycle

S/P Lumpectomy, R

Bronchogenic Carcinoma 1

w/ DM 2

INTERNAL MEDICINEINTERNAL MEDICINENERVOUS SYSTEM

5

Benign Paroxysmal Positional Vertigo 2

w/ Non-Ulcer like Dyspepsia,

Nephrolithiasis© …………………….1

w/ Acute Gastritis …………………….1

Seizure Disorder 1

w/ Maxillary Sinusitis, HPN

CARDIOVARCULAR DISEASE2

Multiple Infarct, L MCA

w/ Seizure Disorder 2ndary to #1

HCVD, Hypercholesterolemia…….1

Pontine Infarct w/ HCVD, CAD…………..1

INTERNAL MEDICINEINTERNAL MEDICINEENDOCRINE SYSTEM

1

Hypoglycemia 1

2ndary to Poor Food Intake, DM 2

w/ CAP- Moderate Risk

INTERNAL MEDICINEINTERNAL MEDICINE

INFECTIOUS 18

Systemic Viral Infection 2

Dengue Fever 4

Stage II

Typhoid Fever 2

w/ HPN …………………1

Acute Gastroenteritis 5

w/ some Dehydration 4

w/ Maxillary Sinusitis …………..1

w/ Moderate Dehydration 1

Intestinal Amoebiasis 2

w/ Mixed Hemorrhoids ……………1

Hepatitis A Infection1

w/ Cholelithiasis

Ŧ Septic Shock Syndrome 1

2ndary to CAP - High Risk

w/ Concomittant Non-ST Elevation

Myocardial Infarction

Human Immunodeficiency Virus Positive 1

w/ Multiple Intracranial Enhancing Lesion (Toxoplasmosis),

UGIB probably 2ndary to Stress Ulcers Gastropathy – Resolved.

w/ Herpes Zoster, R Thigh - Resolved

Mortality # 1Mortality # 1

T. D, 78 y.o., female, widowMabolo, Cebu CityCC: dyspnea, upper back painPast Medical History: HPN, DM2Numbers of Hospital Stays: 5 days

Final DiagnosisFinal Diagnosis

PROBABLE AORTIC DISSECTION, PROXIMAL AORTA

HYPERTENSIVE CARDIOVASCULAR DISEASE

DIABETES MELLITUS 2

Mortality # 2Mortality # 2

N.C., 50 y.o., male CC: epigastric pain, dyspneaPast medical History: HPNNumbers of Hospital Stay: 4 Hours

Final DiagnosisFinal Diagnosis

Septic Schock Syndrome 2ndary to CAP High Risk with Concomittant Non-ST Elevation Myocardial Infarction

MORBID CASEMORBID CASE

V.V., 21y.o., maleMedical RepresentativeTalamban, Cebu CityCC: fever, headache, changes in

behavior

(-) HPN, (-) DM, (-) BAVICES: alcoholic beverage drinker,

smokerAllergy: shrimpHFD: BA

PAST MEDICAL HISTORYPAST MEDICAL HISTORY

2009 – AGE (PSH)

April 2010 – Pneumonia (PSH)

June – Nov. 2010 – PTB (CVGH)

Oct. 2010 – Optic Pneuritis & Glaucoma 2ndary to adverse drug reaction to Ethambutol.

HPIHPI

2 wks PTA – undocumented on & off fever.

No History of cough.

5 Days PTA – still with fever associated with body malaise & headache.

Day PTA – changes of behavior.

BP: 130/90mmHg HR: 86bpmRR: 20cpm T: 36.1CSkin: no lesions, warmHEENT: anecteric, dilated R pupil (5mm) & non-

reactive to light. (+) L eye reactive to Light Neck:(-) LAD, no neck rigidityC/L: ECE, CBS, (-)rales, (-)wheezeCVS: DHS, NRRR, no murmurAbd.: flat, NABS, nontender, no massGUT: (-)KPSExt. : No edema, strong pulses, no limitation in

movement

CNS: drowsy, incoherent, follows command

I – N/A

II, III, - dilated R pupil & non-reactive to light, L pupil is reactive to light.

III, IV,VI – (+)EOM

V, VII – No facial asymmetry

IX, X, XI – (+) gag reflex, tongue at medline, able to swallow & protrude tongue

XI – no shoulder lag

Sensory: Intact

Motor Strength: 5/5 all extremities

Reflexes: RU = +2 LU = +2

RL = +2 LL = +2

(-) Babinski sign

(-) Kernigs sign

(-) Brudzinsky sign

Admitting Impression:Admitting Impression:

R/I Bacterial Meningitis vs.

Space occupying Lesion

On Admission:On Admission:

Hypoallergenic Diet O2 inhalation at 2Lpm. IVF started @ 30gtt/min. Labs: CBC, U/A, Na, K, CXR, crea, CT-scan brain

plain Meds: Vit. B – complex 1 tab OD.

Mefenamic acid 500mg 1cap now. Ceterizine 10mg 1tab OD Ceftriaxone 2G IVTT q 12Hr.

Laboratory Results:Laboratory Results:

CBCWBC = 4.97N = 63L = 20M = 7E = 10Plt = 189Hb = 12.3Hct = 35.7

U/A

Glucose (-)

Protein (-)

pH 1.010

RBC = 0-2

WBC = 0-2

Epithelial = rare

Mucus = rare

Bacteria = rare

CXR

No Significant Findings Na = 133

K = 3.77 Crea = 0.96

CT-SCAN BRAIN PLAINCT-SCAN BRAIN PLAIN

Areas of ill-defined hypodensities with mass effect in the R basal ganglia, R frontal & R temporal lobes, R thalamus & R midbrain.

Consideration include:

1. Cerebritis

2. Vasogenic Edema

3. Infection from Vasculitis

Course in the Ward: Day 1-3P: fever, headache, rashesO: BP: 120/80-140/90 HR: 80-110bpm

RR: 20-24cpm T: 37.5-39CSkin: (+) maculopopular rash, warmHEENT: anecteric, dilated R pupil (5mm) & non-

reactive to light. (+) L eye reactive to Light Neck:(-) LAD, no neck rigidityC/L: ECE, CBS, (-)rales, (-)wheezeCVS: DHS, tachycardic, no murmurAbd.: flat, NABS, nontender, no massExt. : No edema, strong pulses, no limitation in

movement

A: CNS INFECTION, R/I HIV INFECTION

P:For MRI of the brain w/ contrast.

> Rpt CBC For HIV Test & VDRL. For co-mgt w/ Neurologist. Refer to Allergology for clearance. Co-mgt w/ Infectious Specialist. Keppra 500mg 1tab BID. Mannitol 100cc IV q 6H. Iterax 50mg 1tab OD. d/c Ceftriaxone.

MRI OF THE BRAIN w/ ContrastMRI OF THE BRAIN w/ Contrast

Mulltiple minimally enhancing cerebellar and brain stem lesion w/ perilesional edema and mass effect.

Primary consideration is an infectious CNS process such as Toxoplasmosis.

HIV Test

HIV Ag/Ab

457.71 s/co

Remarks: Positive

VDRL Test

Qualitative Result– Negative

CBCWBC = 3.72N = 54L = 26M = 8E = 12Plt = 165Hb = 12.1Hct = 32.5

Day 4 - 5P: fever, no verbal output but patient response

upon calling his name, (+) rashes, unable to eat O: BP: 110/70-140/90 HR: 80-150bpm

RR: 20-25cpm T: 39-41C

Skin: (+) maculopopular rash, warmHEENT: anecteric, dilated R pupil (5mm) & non-

reactive to light and half open. Neck:(-) LAD, no neck rigidityC/L: ECE, CBS, (-)rales, (-)wheezeCVS: DHS, tachycardic, no murmurAbd.: flat, NABS, soft, nontender, no massExt. : No edema, strong pulses, no limitation in

movement

A: HIV Infection, R/I CNS Infection (Toxoplasmosis vs. Lymphoma)

UGIB etiology to be determine

P: NPO & NGT inserted.

- for HbsAg and anti-HCV determination.

- Piperacillin-Tazobactam 4.5G IV then 2.5G IV q 6H.

- Nexium 40mg IVTT OD.

- Fansidar 25/500mg 4tabs now then 1tab q 8H once coffee ground vomitus disappeared.

- all P.O meds shifted to IV.

HbsAg = 1 (NR)

Anti-HCV = 1 (NR)

2 blood culture: negative

Day 6 - 8P: fever, no verbal output but response upon

calling his name, recurrence of coffee ground NGT drainage, (+) vesicular rash

O: BP: 110/70-130/90 HR: 85-140bpm

RR: 20-22cpm T: 38-40C

Skin: warmHEENT: anecteric, dilated R pupil (5mm) & non-

reactive to light and half open. Neck:(-) LAD, no neck rigidityC/L: ECE, CBS, (-)rales, (-)wheezeCVS: DHS, tachycardic, no murmurAbd.: flat, NABS, soft, nontender, no massExt. : No edema, (+) vesicular rash on the R thigh,

strong pulses, w/ limitation in movement on the L side of the body.

A: HIV Infection, R/I CNS Infection (Toxoplasmosis vs. Lymphoma)

UGIB etiology to be determine, Herpes Zoster R Thigh

P: NGT feeding started.

- for CD4 count and Toxoplasma Serologic IgG & IgM determination.

- hold fansidar.

- Zithromax 500mg IV drip OD.

- Dalacin 300mg 1tab/NGT q 6H hold

- Valtrex 1G 1tab q 8H/NGT hold

Dexamethasone 50mg IVTT q 6H. Zovirax 500mg IV infusion. Kabiven 1.4Kcal to run q 24H. Ice bath done. Refer to Neurosurgeon for possible brain

biopsy.

Day 9 - 12P: fever, no verbal output but response upon

calling his name, (+) vesicular rash, (+) Chyne-Stokes respiration

O: BP: 110/70-140/80 HR: 85-160bpm

RR: 20-23cpm T: 37.5-40.8C

Skin:warmHEENT: anecteric, dilated R pupil (5mm) & non-

reactive to light and half open. Neck:(-) LAD, no neck rigidityC/L: ECE, CBS, (+)rales both Lung field, (-)wheezeCVS: DHS, tachycardic, no murmurAbd.: flat, NABS, soft, nontender, no massExt. : No edema, (+) vesicular rash on the R thigh,

strong pulses, w/ posturing/extension of L upper extremities.

A: HIV Infection, R/I CNS Infection (Toxoplasmosis vs. Lymphoma)

UGIB probably 2ndary to Stress Ulcer, Herpes Zoster R Thigh

P: - Rpt CXR done.

- Resume Valtrex.

- Paracetamol given RTC.

- Mucosta 100mg 1tab BID.

- Hold Pepiracillin.

- Cefipime 2G IVTT q 12H.

-

Acetylcytine 600mg mix in water BID. Salbutamol nebulization q 6H. Inc. Keppra 100mg 1tab BID. Inc. Mannitol 100cc q 6H. Family appraised for brain biopsy.

Day 13 - 21 P: fever, no verbal output but response upon

calling his name O: BP: 100/70-140/80 HR: 90-143bpm

RR: 19-23cpm T: 37.4-39.8C

Skin:warmHEENT: anecteric, dilated R pupil (5mm) & non-

reactive to light and half open. Neck:(-) LAD, no neck rigidityC/L: ECE, CBS, (+)rales both Lung field, (-)wheezeCVS: DHS, tachycardic, no murmurAbd.: flat, NABS, soft, nontender, no massExt. : No edema, strong pulses, w/ limitation in

movement on the L side of the body.

A: HIV Infection, R/I CNS Infection (Toxoplasmosis vs. Lymphoma)

UGIB probably 2ndary to Stress Ulcer, Herpes Zoster R Thigh

P: - continue all meds.

- family opted to transfer to other hospital for further mgt.

CD4 = 13.23

(N.V 535-1451) CD8 = 68.82

(n.v. 139-783) CD4/CD8 = 0.2

(N.V. 1.5:1-2.7:1)

Markedly decrease T. Lymphocytes.

Markedly decrease Helper T cells.

Normal T-suppressant population.

HIV Confirmatory Test

CLEIA: Reactive

Ag/Ab = 270.08

(N.V. >3.500)

Toxoplasma Serologic Test

IgG Ab to Toxoplasma Gondii

366.6 IU/mL– Reactive

IgG Ab to Toxoplasma Gondii= 0.49 IU/mL (n.v ≤0.600)

negative

FINAL DIAGNOSISFINAL DIAGNOSIS

Human Immunodeficiency Virus Positive 1

w/ Multiple Intracranial Enhancing Lesion (Toxoplasmosis),

UGIB probably 2ndary to Stress Ulcers Gastropathy – Resolved.

w/ Herpes Zoster, R Thigh - Resolved