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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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J m ca ete 2 mos m san pedro laguna

J.M.CAŃETE2 mos/MSan Pedro, Laguna

CC: Burn

DOA: 10/20/10

DOR: 10/25/10

CN: 3622389


History present of illness
HISTORY PRESENT OF ILLNESS

NOI: Burn Injury

TOI: 10 AM

DOI: 10/20/10

POI: Patient’s Residence


History present of illness1
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  @


Review of systems
REVIEW OF SYSTEMS

  • (-) fever

  • (-) weight loss

  • (-) headache

  • (-) cough

  • (-) colds

  • (-) difficulty of breathing

  • (-) chest pain

  • (-) changes in BM and urine output

  • (-) cyanosis

  • (-) seizures


Past medical history
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


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.


Physical examination at er
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


Course
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


Course1
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


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


Pe upon referral
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


  • 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


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


Metabolic

  • (+) hypoalbuminemia

  • (+) hypocalcemia

  • Calcium gluconate (100) given

  • Ref to GI, seen & examined, albumin 1 vial transfused (11/4)


Events prior to demise
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


Events prior to demise1
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)


Events prior to demise2
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


Events prior to demise3
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


PCOD

  • Septic Shock





  • 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


R garabel 1 m gen trias cavite

R. GARABEL1/MGen. Trias, Cavite

CC: Loose Bowel Movement

DOA: 11/5/10

DOR: 11/5/10

LOS: 2 days


History present of illness2
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


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  @


Review of systems1
REVIEW OF SYSTEMS appetite, activity; no change in sensorium

  • (-) weight loss

  • (-) headache

  • (+) ear discharge x 7 days, “parang nana”

  • (-) difficulty of breathing

  • (-) chest pain

  • (-) changes in BM and urine output

  • (-) cyanosis

  • (-) seizures


Past medical history1
PAST MEDICAL HISTORY appetite, activity; no change in sensorium

  • (-) 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


  • IMMUNIZATION HISTORY appetite, activity; no change in sensorium

  • 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.


Physical examination
PHYSICAL EXAMINATION appetite, activity; no change in sensorium

  • 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


Neurologic exam
NEUROLOGIC EXAM appetite, activity; no change in sensorium

  • 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


Impression
Impression: appetite, activity; no change in sensorium

  • Acute Gastroenteritis with severe signs of Dehydration

  • Acute Otitis media

  • Community acquired Pneumonia

  • Septic Shock


Course at per
COURSE at PER appetite, activity; no change in sensorium

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)


  • At the 8th hr, (+) hypotension (BP 70/40) appetite, activity; no change in sensorium

  • 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


Respiratory appetite, activity; no change in sensorium

  • 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


Course at per1
COURSE at PER appetite, activity; no change in sensorium

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)


Course at the wards
COURSE AT THE WARDS appetite, activity; no change in sensorium

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


Respiratory appetite, activity; no change in sensorium

  • MV: 100 20/5 20 .5

  • Serial ABG monitoring done, showed Respiratory Alkalosis

  • Weaning MV setting done


Cardiac appetite, activity; no change in sensorium

  • IVF: FM + 70% (including inotropes)

  • Voluven (50cc/kg) started, IVF dec to TFI 150

  • Dopamine (20), Dobutamine (20),

    Epinephrine (.5)  (1)


Metabolic appetite, activity; no change in sensorium

  • 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


Infectious appetite, activity; no change in sensorium

  • Pen G (200,000) D1+2

  • Amikacin (15) D1

  • Aural toilette done

    Hematologic

  • s/p 1 u PRBC (15 cc/aliq)


Course leading to the demise
COURSE LEADING TO THE DEMISE appetite, activity; no change in sensorium

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


PCOD appetite, activity; no change in sensorium

  • Septic Shock


CBC appetite, activity; no change in sensorium


ABG appetite, activity; no change in sensorium


Blood chemistry1
Blood appetite, activity; no change in sensoriumChemistry


Bongalos earl john 11 mos m

BONGALOS, Earl John appetite, activity; no change in sensorium11 mos/M

Mauban, Quezon

DOA: 9/27/10

DOR: 11/ 11/10

LOS: < 24 hrs

CN: 3618146


History present of illness3
HISTORY PRESENT OF ILLNESS appetite, activity; no change in sensorium

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


History present of illness4
HISTORY PRESENT OF ILLNESS appetite, activity; no change in sensorium

1 month PTC mass ruptured releasing a foul smelling discharge

(+) increase in size

(+)Consult :unrecalled antibiotics; sent home

1 day PTC progression of mass

(+)Consult, A>infected mass

Tx:Cefuroxime and Metronidazole

Referred to our institution


Review of systems2
REVIEW OF SYSTEMS appetite, activity; no change in sensorium

  • (-) fever

  • (+) weight loss associated with poor intake

  • (+) anorexia

  • (-) headache

  • (-) cough

  • (-) colds

  • (-) difficulty of breathing

  • (-) chest pain

  • (-) changes in BM and urine output

  • (-) cyanosis

  • (-) seizures


Past medical history2
PAST MEDICAL HISTORY appetite, activity; no change in sensorium

  • (-) no known allergies

  • (-) no previous surgeries

  • (-) no previous illnesses

    FAMILY MEDICAL HISTORY

  • unremarkable

    BIRTH/MATERNAL HISTORY

  • Full term to a 32 year old G1P0 via SVD c/o hilot at home

  • 6 PNCU at LHC

  • (-) maternal illness (-)fetomaternal complications

  • At birth: good cry, good suck and good activity


Immunization history
IMMUNIZATION HISTORY appetite, activity; no change in sensorium

  • Complete EPI

  • NUTRITIONAL HISTORY

  • Breast fed until 6 months. The patient is on Pedia sure up to present.

  • DEVELOPMENTAL HISTORY

  • Able to prone-supine position

  • Able to say “la”, “pa”, “ma”, “ate”

  • PERSONAL AND SOCIO-ECONOMIC HISTORY

  • Patient is an only child of a 33 year old unemployed mother and a 29 year old fish vendor


Physical examination at per
PHYSICAL EXAMINATION at PER appetite, activity; no change in sensorium

  • Awake, afebrile, not in cardiorespiratory distress

  • VS BP 80/50, HR 140-150, RR 40s T afebrile, O2 sats 99%

  • Pink palpebral conjunctiva, anicteric sclera

  • Moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged, supple neck, (+) CLAD

  • Equal chest expansion, clear breath sounds, no retractions

  • Adynamicprecordium, distinct heart sounds, tachycardic, regular rhythm, no murmurs

  • Soft, globular, nontender abdomen, normoactive bowel sounds, no organomegaly

  • Pulses full and equal, CRT <2 sec, no edema, no cyanosis

  • (+) 10x 8 x 7cm hard, non movable, left ankle mass with foul smelling discharged with necrotic tissue


Course at the per
COURSE AT THE PER appetite, activity; no change in sensorium

  • S/O>gradually enlarging mass L ankle that progress into an abscess which ruptured releasing a foul smelling discharge

    (+)generalized pallor, tachycardic, good pulses

    (+) 10x8x7 cm soft non movable left ankle mass with foul smelling discharge (+) necrotic tissue

    A> Left ankle mass probably osteosarcoma with superimposed bacterial infection


Course at the per1
COURSE AT THE PER appetite, activity; no change in sensorium

P> O2 support at 10 lpm

t/s Ceftazidime (100 mkd), Oxacillin (200) and Amikacin

Laboratories were facilitated

CBC: Hgb 29, Hct 0.081 WBC 50 N 0.6 L 0.28

Blood CS, electrolytes

Referred to Ortho and Hema Onco service


Course at the wards hematologic
COURSE AT THE WARDS: appetite, activity; no change in sensoriumHEMATOLOGIC

1ST Hospital day

  • S/O> (+) generalized pallor, tachycardia, bleeding per mass

  • A> Left ankle mass probably osteosarcoma with superimposed bacterial infection

  • P> BT pRBC 2 aliquots x 2doses

    5th hospital day:seen by Ortho: MRI of the left thigh


Hematologic oncologic
HEMATOLOGIC- ONCOLOGIC appetite, activity; no change in sensorium

  • 30th hospital day: MRI of the leg: Enlarged expansive mass measuring 18.7 x 7 x 12.3 predominantly cystic which is multi-septated and multi-loculated at the posterolateral aspect of the lower leg, expanding medially. Note of buckling and abnormal bone growth of the left tibia and fibula, heterogenous enhancing mass 6.95 x 4.69 x 3.55 cm mass with cystic mass component and areas of necrotic. The assessment was hemangioma-lymphangioma complex.

  • Orthopedic service is to do biopsy of the mass because they were considering another tumor.


Hematologic oncologic1
HEMATOLOGIC- ONCOLOGIC appetite, activity; no change in sensorium

  • 32nd hospital day:

    S/O> weak looking , with generalized pallor, pale conjunctiva, fair pulses and CRT of 3 seconds. VS :HR 120, RR 24-28.

    CBC: Hgb 60 Hct 0.187

    P> BT pRBC 3 aliquots

    Repeat CBC: Hgb 156 Hct .453

    41st hospital day:

    (+) bleeding per mass

    CBC: Hgb 80, 0.234

    PT, PTT: 10.8/26.5/0.04/11.40 34.4/ 176

    t/s Vitamin K, BT pRBC and FFP q8h


  • MRI done showed appetite, activity; no change in sensoriumHemangioma Lymphangioma complex


Course at the wards infectious
COURSE AT THE WARDS: INFECTIOUS appetite, activity; no change in sensorium

1st hospital day

  • S/O>gradually enlarging mass L ankle progressing into an abscess which ruptured releasing a foul smelling discharge

  • (+) 10x8x7 cm soft non movable left ankle mass with foul smelling discharge (+) necrotic tissue

  • P> Ceftazidime (100 mkd), Oxacillin (200) and Amikacin

  • Blood CS upon admission: NG D5


Course at the wards infectious1
COURSE AT THE WARDS: INFECTIOUS appetite, activity; no change in sensorium

  • 12TH Hospital day: (+) Fever Tmax 38C, fair activity, no alar flaring, clear BS

  • A>t/c Nosocomial Sepsis

  • P> Repeat sepsis

    CBC: Hgb 126, Hct 0.367 WBC 14.57, N 0.478, L 0.367 M 0.133, E 0.04 platelet 85

    Blood CS: P. putida


Course at the wards infectious2
COURSE AT THE WARDS: INFECTIOUS appetite, activity; no change in sensorium

26th-30th hospital day: fever Tmax 39, good suck fair cry

Repeat sepsis work up

CBC: Hgb 156, Hct .453 WBC 69.88 N .704

A> t

t/s Cefepime (150) and Amikacin (15)

MIC to Cefepime done


Course leading to the demise1
COURSE LEADING TO THE DEMISE appetite, activity; no change in sensorium

  • 44TH Hospital day

    S/O: (+) fair activity, good suck

    HR: 150 RR 60s T 38C, (+) in cardiorespiratory

    distress (+) alar flaring, (+) retractions, clear BS

    A> new onset Nosocomial Pneumonia r/o Nosocomial Sepsis

    P> sepsis work up

    CXR: no new infiltrates

    Shift antibiotics: Meropenem(120), t/s Vancomycin (60)

    ABG at 10 lpm: 7.387/8.7/172/5.2/-16.4/99.1

    20 cc/kg PNSS bolus given; inc TFI 130

    Repeat ABG: 7.44/14.8/197.5/10.1/-10.7/99.4

    20 cc/kg bolus PNSS and increase TFI to 150


Course leading to the demise2
COURSE LEADING TO THE DEMISE appetite, activity; no change in sensorium

45th hospital day

  • S/O: (+) persistent of respiratory distress and acidotic breathing: RR 60s HR 150s T afebrilealar flaring, crackles BLF, poor pulses, CRT 6 seconds, warm extremities

  • Intubation done ET4L11.5 under RSI

  • Give 20 cc/kg PNSS bolus

  • T/s Dopamine 10mcg/kg/min

  • ABG at 100, 20/5, 40, 0.5

    7.257/32.9/134.6/14.7/-11.2/98.1

    2 meqs NaHCO3 given


Course leading to the demise3
COURSE LEADING TO THE DEMISE appetite, activity; no change in sensorium

  • Give Voluven 10 cc/kg to run for 1 hour

  • IVF: D5LR + Voluven: FM + 50%

  • LABS noted: wound CS

  • Moderate growth of A. baumanii, Citrobacter freundi, high level aminoglycoside resistant enterococcus

  • Repeat CXR: wiped out lung RLF, PF ratio 109


Course leading to the demise4
COURSE LEADING TO THE DEMISE appetite, activity; no change in sensorium

  • Noted no spontaneous breathing: last BP 70/40 HR 400 O2 sat 68%

  • Code was called, CPR was done; hooked to CAB

  • Epinephrine via IV and ET given

  • Dopamine and Dobutamine at 20 mcg/kg/min

  • Epinephrine at 0.5 mcg/kg/min

  • Revived after 3 minutes

  • Patient coded again after 3 hours

  • Patient was not 31 mins of code

  • Post-mortem biopsy of mass done


PCOD appetite, activity; no change in sensorium

  • Septic Shock

  • Hemangioma Lymphangioma comples with superimposed bacterial infection

  • Nosocomial Sepsis (P.putida)

  • New-onset Nosocomial Sepsis (B. pseudomallei)


Mri of left leg with contrast
MRI of Left Leg, with Contrast appetite, activity; no change in sensorium

  • There is an enlarged expansile mass measuring 18.72x7x12.31 cm which is predominantly cystic which is multi-septated, and multi-loculated and seen in the poster-lateral aspect of the left lower leg and expanding medially. The mass is hypointense on T1W images, and highly intense on T2W images. The calf muscles are no longer deliniated. There is note of enhancement on the base of the mass on contrast contrast study.

  • There is note of buckling and abnormal bone growth of the left tibia and fibula.

  • There is also heterogenously enhancing .95x 4.69x3.55 cm mass with custic components and with areas of necrosis. The mass has intermediate intensity at the medial aspect of the left thigh. The hamstring muscles are not well-differentiated.

  • Both femoral heads and acetabula, as well as the maow signal are within normal limits. No femoral head subluxation nor dislocation seen.

  • Impression: hemangioma-Lympangioma complex


CBC appetite, activity; no change in sensorium


CBC appetite, activity; no change in sensorium


ABG appetite, activity; no change in sensorium


Blood chemistry2
Blood Chemistry appetite, activity; no change in sensorium


Blood chemistry3
Blood Chemistry appetite, activity; no change in sensorium


  • Blood CS appetite, activity; no change in sensorium

    (11/11) B. Pseudomallei after 7.44 hours

    MIC Recommended

    (10/29) Pseudomonas putida after 21.6 hrs

    S: Cefepime, Meropenem

  • Blood CS

    (10/9) Pseudomonas putida after 17 .4 hrs

    MIC Recommended

  • (11/4) Wound swab GS: No PMN/

    Gram (-) bacilli 0-2

    Gram (+) cocci in pairs 0-2

    Wound CS: Acitenobacter baumanii (S: Ampi-sul/Cefta/Imip; R: Genta)

    Citrobacter freundii (S: Erta/Merop/Imip; R: Amik, Co-amox, Aztreo, Cefox, Cefep, Ceftri, Cefu, Genta)

    HLARE (S: Ampi, Pen G, Vanco)