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Canete Garabel Bongalos

Canete Garabel Bongalos. J.M.CAŃETE 2 mos /M San Pedro, Laguna. CC: Burn DOA: 10/20/10 DOR: 10/25/10 CN: 3622389. HISTORY PRESENT OF ILLNESS. NOI: Burn Injury TOI: 10 AM DOI: 10/20/10 POI: Patient’s Residence. HISTORY PRESENT OF ILLNESS.

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Canete Garabel Bongalos

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  1. Canete • Garabel • Bongalos

  2. J.M.CAŃETE2 mos/MSan Pedro, Laguna CC: Burn DOA: 10/20/10 DOR: 10/25/10 CN: 3622389

  3. HISTORY PRESENT OF ILLNESS NOI: Burn Injury TOI: 10 AM DOI: 10/20/10 POI: Patient’s Residence

  4. HISTORY PRESENT OF ILLNESS 3 Hrs PTA, patient was lying supine on the floor when his mother accidently spilled hot water on the floor where it flowed to the patient . He sustained scald burn on his trunk, (B) upper and lower extremities Patient was brought to local hospital where wound dressing was done. Family opted to transfer to PGH  @

  5. REVIEW OF SYSTEMS • (-) fever • (-) weight loss • (-) headache • (-) cough • (-) colds • (-) difficulty of breathing • (-) chest pain • (-) changes in BM and urine output • (-) cyanosis • (-) seizures

  6. PAST MEDICAL HISTORY • (-) no known allergies/ previous surgeries/ previous illnesses FAMILY MEDICAL HISTORY • (-) Allergy/ HPN/DM/PTB/ Cancer • (+) BA: paternal grandmother BIRTH/MATERNAL HISTORY • Full term to a 22 y/o G2P1 (1001) mother via SVD c/o midwife at home • PNCU at LHC • (-) maternal illness (-)fetomaternal complications • At birth: good cry, good suck and good activity

  7. IMMUNIZATION HISTORY • None NUTRITIONAL HISTORY • Breast fed until admission DEVELOPMENTAL HISTORY • Able to lift head in supine • (+) visual tracking PERSONAL AND SOCIO-ECONOMIC HISTORY • Patient is 2nd child of a 22y/o unemployed mother and a 20 y/o restaurant crew. Family lives in 2nd floor, studio-type.

  8. PHYSICAL EXAMINATION at ER • Awake, crying, not in cardiorespiratory distress • VS HR 130s RR 36 T 37.3 • Pink palpebral conjunctiva, anicteric sclera • Moist buccal mucosa, tonsils not enlarged, supple neck, (-) CLAD • Equal chest expansion, no retractions, clear breath sounds • Adynamicprecordium, distinct heart sounds, regular rhythm, no murmurs • Soft, globular, nontender abdomen, normoactive bowel sounds, no organomegaly • Pulses full and equal, CRT <2 sec, no edema, no cyanosis • (+) scald burn (R) upper extremities, B LE, R scapula

  9. COURSE Surgical • Patients obtained scald burn 15% TBSA • L cheek • (R ) scapular area • Flexor areas (R) upper extremities • Extensor areas (R ) LE, w/ Achilles tendon • distal third of (L) LE, flexor side, w/ Achilles tendon

  10. COURSE • Operations: 1.) (10/23) Tangential Excision & Split Thickness Skin Graft • Donor sites: (L) circumferential thigh (R ) Anterior thigh (A) Abdomen • Excision sites: (R&L) foot (R) hand & R Ant Chest • OR time 3 hrs • HR 140-160; no BP and Temperature monitoring • Blood Loss 70 cc; UO 5 cc/kg/hrx 3 hrs 2.) (10/28) 2nd graft site opening

  11. Infectious • S: (+) fever on 2nd POD • O: BP 90/60 126 53 35.7 38.2 • A: Scald burn w/ superimposed Bacterial Infection, t/c Nosocomial Sepsis • P: started post-op on Ceftazidine (100) D0+2 and Amikacin (15mkd) D1 • Shifted to Meropenem (100mkd) increased to (120mkd) D8+1 • Shifted to Oxacillin when Tissue GS/CS (10/24) GS: No PMN; No organism seen • Culture: Moderate growth of Staphylococcus aureus • (S: Clinda, Erythro,Oxa; R: PenG) • Referred to PICU

  12. PE upon Referral: • HR 140s RR 40 T 36.5 W 6 kg H 50 HC 38.5 • Awake, crying • Pink palpebral conjunctiva, anicteric sclera • Moist buccal mucosa, tonsils not enlarged, supple neck, (-) CLAD • Equal chest expansion, no retractions, clear breath sounds • Adynamicprecordium, distinct heart sounds, regular rhythm, no murmur • Soft, globular, nontender abdomen, normoactive bowel sounds, no organomegaly • Pulses full and equal, CRT <2 sec, no edema, no cyanosis • (+) burn: L cheek; Flexor areas (R) upper extremities, Extensor areas (R ) LE, w/ Achilles tendon distal third of L LE, flexor side, w/ Achilles tendon (R ) scapular area

  13. Neuro Exam: • CN: pupils 2 mm EBTRL, brisk corneals, (-) facial asymmetry, turns to sound, intact gag refles, turns head side to side, tongue in midline • Motor: full range of motions • Sensory: withdraws to pain • DTRs: 2+ • Meningeals: (-) nuchal rigidity • (+) Babinski, (-) clonus A> Scald burn 15% TBSA, (R) hand, (R) anterior chest P> Dx: ABG, 13-L ECG IVF: D5 IMB + 50 meqs KC/L (.32meqs/kg/min) (TFI FM+40) O2 at 5 lpm via FM Tx: Merop (100 120mkd); Paracetamol, Silver sulfadiazine, Omeprazole

  14. Respiratory • S: (+) crackles , tachypnea and retractions on 1st POD • O: BP 90/60 126 53 35.7 38.2 SCE, (+) crackles • A: Nosocomial Pneumonia • P: Salbutamol neb; antibiotics • Noted improvement • PICU signed out on 14th HD, 11th & 6th POD

  15. Metabolic • (+) hypoalbuminemia • (+) hypocalcemia • Calcium gluconate (100) given • Ref to GI, seen & examined, albumin 1 vial transfused (11/4)

  16. Events Prior to Demise • On 16th HD, 13th & 8th POD, • Noted crackles w/ occ wheezes • + bullae formation on bilateral LL, edema • VS: HR 160 BP 80/60 RR 70s T 36.6 • ABG (compensated metabolic acidosis) 7.455/ 21.7/ 178.9/ 15.3/ -5.4/ 99.3 at O2 support 5 lpm via FM • CXR: upper and perihilar infiltrates • A> New onset Nosocomial Pneumonia r/o Staph Pneumonia t/c Nosocomial Sepsis

  17. Events Prior to Demise • Referred back to PICU • O2 support at 10 lpm  Intubated ET 4.5 L11 • Repeat sepsis work-up • CBC: 72/.218/14.23/.67/.24/.07/.006/.001/152 • ABG: 7.23/48.8/57.9/20.7/-6.1/83.6 (Respiratory acidosis) • CXR- CTR: .52 perihilar infiltrates, - effusion, ET adjusted to L1110 • Shifted to Vancomycin (60), while not available: Oxa (200) Amik (15) Cefepime (100)

  18. Events Prior to Demise • On 17th HD, 14th & 9th POD (9am) • BP 90/50 HR 150s RR 60s T 36.7 • Obtunded • Symmetrical chest expansion, crackles (B) LF • AP, DHS, tachycardic, no muurmur • Globular abd, AG widest: 60, umbilical 39.5 • Poor pulses, cold extremities,CRT 4 sec • Inotropic support revised: Dopamine (10)/ Dobutamine (10) • Meropenem increased to 200mkd

  19. Events Prior to Demise • 12 nn • BP 70/40 HR 86 RR 50 T 36.2  code • PE: tachycardic 160-170s, crackles (B) • A> Septic shock, ARDS • CPR done, revived after 3 minutes • Inotropic support revised: Dopamine (20)/ • Epinephrine (.1) • ABG 7.210/55/100/22/-5.5/95.9 PFR 100.4 at setting of 100 22/5 60 .5 • PIP inc to 28 PEEP 8 • Started Omeprazole • For BT of pRBC (15 cc), not facilitated • Head cooling x 24 hrs • Coded, never revived

  20. PCOD • Septic Shock

  21. CBC

  22. ABG

  23. Blood Chemistry

  24. Blood CS (10/24) AB: No growth after 5 days (10/29) No growth after 5 days • Tissue Culture (10/24) GS: No PMN; No organism seen Culture: Moderate growth of Staphylococcus aureus (S: Clinda, Erythro,Oxa; R: PenG) • Wound swab GS: (11/3) Wound CS: Pseudomonas putida (I: Aztreo; R: Amik, Cefta, Ceftri, Cipro, Imip, Merp,Pip-Tazo) MRSA (S: Linezolid; R: Clinda, Erythro, Genta, Oxa, Pen G, Vanco ) • Urine GS/CS (10/24): No PMN, no organism; No growth after 2 days

  25. R. GARABEL1/MGen. Trias, Cavite CC: Loose Bowel Movement DOA: 11/5/10 DOR: 11/5/10 LOS: 2 days

  26. HISTORY PRESENT OF ILLNESS 7 days PTA, (+) LBM , 7x, greenish, mucoid, non-bloody, w/ undocumented fever; (-) abd distension/pain/ vomiting (+) productive cough, whitish phlegm (-) difficulty of breathing (-) medication given/ consultlation done 4 days PTA, patient was still w/ LBM and cough. (+) consult at LHC, given ORS, no resolution of LBM

  27. 3 days PTA, still w/ LBM, this time, noted w/ decreased appetite, activity; no change in sensorium Few hours PTA, there was persistence of symptoms, with noted decreased in sensorium. Hence brought to PGH  @

  28. REVIEW OF SYSTEMS • (-) weight loss • (-) headache • (+) ear discharge x 7 days, “parang nana” • (-) difficulty of breathing • (-) chest pain • (-) changes in BM and urine output • (-) cyanosis • (-) seizures

  29. PAST MEDICAL HISTORY • (-) no known allergies/ previous surgeries/ previous illnesses FAMILY MEDICAL HISTORY • (-) Allergy/ BA/HPN/DM/ Cancer • (+) PTB, maternal grandmother BIRTH/MATERNAL HISTORY • Full term to a 37 y/o G4P3 (3003) mother via SVD c/o midwife at home • PNCU at LHC • (-) maternal illness (-)fetomaternal complications • At birth: good cry, good suck and good activity

  30. IMMUNIZATION HISTORY • unknown • NUTRITIONAL HISTORY • Breast fed until admission • DEVELOPMENTAL HISTORY • At par with age • PERSONAL AND SOCIO-ECONOMIC HISTORY • Patient is the youngest in brood of four. Mother is 38 yo housewife, father is 48 yo construction worker.

  31. PHYSICAL EXAMINATION • Lethargic, afebrile, not in cardiorespiratory distress • VS BP 70 palp, HR 92, RR 48, T 36.2 O2 sats 99% • Wt 6kg Ht HC • Pink palpebral conjunctiva, anicteric sclera, sunken eyeballs • Dry lips and buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged, supple neck, (+) CLAD, (+) perforated tympanic membrane app 15%, AD • Equal chest expansion, clear breath sounds, no retractions • Adynamicprecordium, distinct heart sounds, bradycardic, regular rhythm, no murmurs • Soft, globular, nontender abdomen, normoactive bowel sounds, no organomegaly • Poor skin turgor, weak Pulses, CRT 4 sec, no edema, no cyanosis

  32. NEUROLOGIC EXAM • MSE: lethargic • CN: 3mm EBRTL; EOMS full & equal; supple neck; Brisk corneals; no facial asymmetry; turns to voice; uvula midline; tongue in midline • Motor: spontaneous & equal movement of all extremities to pain • Reflexes: normoreflexive • Sensory: spontaneous & equal movement of all extremities to pain • Cerebellar:No nystagmus • Meningeal: no neck rigidity

  33. Impression: • Acute Gastroenteritis with severe signs of Dehydration • Acute Otitis media • Community acquired Pneumonia • Septic Shock

  34. COURSE at PER Resuscitation: • Given total of 80cc/kg PLR: BP : 70/40 80/50 • Maintained at 30 cc/hr PLR x 1 hr, 70cc/hr x 5 hrs* • ABG showed metabolic acidosis, pt also had 2 bouts of LBM, BP: 70/40 • Given another 60 cc/kg PLR: BP 70/40 (Noted puffy eyelids) • Started Dopamine(10) • IVF maintained on D5 LR @ FM + 30% • Initial UO after foley cath insertion: 18cc/kg x 8 hrs *(WHO Plan C for the severe dehydration)

  35. At the 8th hr, (+) hypotension (BP 70/40) • Given another 20 cc/kg PLR,  Dopamine (20), rpt BP 100/60, HR 100 Patient was for CXR, during transport, patient had code, ACLS done Revived after 6 mins (HR 100 ) A> CP arrest prob. sec to 1. Hypovolemia; 2. Arrhythmia sec. to Hypokalemia Referred to PICU

  36. Respiratory • Patient with irregular breathing, • Intubated hooked to CAB • Rpt gas showed compensated metabolic acidosis • 2 meqs/kg Na HCO3 given • Repeat still showed compensated metabolic acidosis • Another 2 meqs/ kg NaHCO3 given

  37. COURSE at PER Infectious • Initial CBC: Hgb 70, Hct .221, WBC 17.36, Plt 351 DC: .70/.21/ .075/.001 • Started on Pen G (200,000) (D0+1) • Sepsis work-up facilitated • For BT pRBC (15 cc/kg) x 4 doses Metabolic Initial blood chem: K 2.1, Ca 1.65 ECG: HR 80, reg rhythm, no T wave inversion A>Hypokalemia, hypokalcemia prob sec to GI losses • Calcium gluc (100) given (1out 4 doses) • 40meqs/L KCl incorporated in IVF (del .24 meqs/kg/hr)

  38. COURSE AT THE WARDS PE on referral: • Stupurous, afebrile, intubated • VS BP 110/80 HR 121, RR 28, T 37.1 O2 sats 99% Wt 6kg • Pink palpebral conjunctiva, anicteric sclera, (-) sunken eyeballs, moist mucosa, non-hyperemic posterior pharyngeal wall, supple neck, ET in place, (+) CLAD • Equal chest expansion, good air entry/ chest rise, no retractions • Adynamicprecordium, distinct heart sounds, regular rhythm, no murmurs • Soft, globular, nontender abdomen, normoactive bowel sounds, no organomegaly • FEP, CRT 2 sec, (+) cool extremities, no edema/ cyanosis

  39. Respiratory • MV: 100 20/5 20 .5 • Serial ABG monitoring done, showed Respiratory Alkalosis • Weaning MV setting done

  40. Cardiac • IVF: FM + 70% (including inotropes) • Voluven (50cc/kg) started, IVF dec to TFI 150 • Dopamine (20), Dobutamine (20), Epinephrine (.5)  (1)

  41. Metabolic • Gluc 4.08/ BUN 2.44/ Crea 127/ Alb 14/ Na 133/Cl 194/ K 2.1/ Ca 1.65 • t/s MgSO4 (50mkdose) • Calcium gluconate (100) given • IVF: KCl inc to 60 meqs/L • (+) Hypokalemic: 2.11.4  1.5 2.2 • K correction: (.5meqs/kg) (x 4 doses)  1meq/kg (x 1 dose) • Rpt ECG requested, not done

  42. Infectious • Pen G (200,000) D1+2 • Amikacin (15) D1 • Aural toilette done Hematologic • s/p 1 u PRBC (15 cc/aliq)

  43. COURSE LEADING TO THE DEMISE On 2nd HD, (+) Hypotensive, tachycardic, tachypneic, febrile A> recurrence of shock secondary to progressing sepsis • Total bolus 60 cc/kg PNSS done • BP: 120/70, poor pulses, cold clammy extremities • Another bolus PNSS given, 2 meqs/kg NaHCO3 given • Noted: HR 0 • Never revived

  44. PCOD • Septic Shock

  45. CBC

  46. ABG

  47. Blood Chemistry

  48. BONGALOS, Earl John11 mos/M Mauban, Quezon DOA: 9/27/10 DOR: 11/ 11/10 LOS: < 24 hrs CN: 3618146

  49. HISTORY PRESENT OF ILLNESS 10 months PTA Birth: (+) skin colored pea sized mass , firm in consistency at the medial side of the lower 3rd of the left leg. In the interim, the mass was noted to have increased in size, now violaceous in color 5 months PTA (+) Consult: A>“baradongugat” Referred to Regional Hospital Tx>Cloxacillin and Co-Amoxiclav: no relief

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