Download PGH Form No P

PGH Form No P-310010 (Revised January 2008)
(DATE RECEIVED)
PHILIPPINE GENERAL HOSPITAL
The National University Hospital
University of the Philippines Manila
Taft Avenue, Ermita, Manila
“PHIC Accredited Health Care Provider”
ISO 9001: 2008 Certified
CLINICAL ABSTRACT
Name of Hospital / Ambulatory Clinic:
Case No. 3536446
Admission:
Date: 2/13/2010
Month/Day/Year
Accreditation No.:
Philippine General Hospital
Address of Hospital / Ambulatory Clinic:
No., Street
Barangay:
MALATE
Taft Avenue
Municipality / City:
Time: 10:20PM
Province:
Manila
Zip Code:
NCR
1000
PATIENT’S CLINICAL RECORD
1.
Patient Name
2.
Last Name
19
DULAY
First Name
Age
3.
Sex
MALE
4.
DONI RAYMUND
Middle Name
SANDAGON
5.
Printed Name & Signature of Admitting Officer
Admitting Diagnosis
Organophosphate Poisoning, severe
In Intermediate Syndrome
Acute Kidney Injury secondary to Rhabdomyolysis
Stress Hyperglycemia
r/o Aspiration Pneumonia
6.
Chief Complaint
Insecticide ingestion
7.
Reason for Admission
For medical management
8.
Brief History of Present Illness / OB History:
Patient Profile: The patient is a 19 year-old male, single, Roman Catholic, from Makati who was admitted in this institution last February 13, 2010. The patient is
an asthmatic (last attack was at 6 years-old), non-hypertensive and non-diabetic with a <1 pack-year smoking history since 2008 and an occasional alcoholic
beverage drinker.
11 hours prior to admission, the patient accidentally ingested about half a cup (<50cc) of “Termite X” which was stored inside a bottle of mineral water near
the refrigerator. The patient then tried to induce vomiting. He had successfully vomited clear fluid thrice. He also tried to brush his teeth to get rid of the smell.
After 2 hours,he was seen with white frothy discharge per orem and was weak-looking. He was rushed to a clinic where oxygen and unrecalled medications
were given. Notable were loose bowel movement, watery, pesticide-smelling stools (3x). The patient was immediately brought to a local hospital where the
patient was examined to be drowsy but arousable, but agitated when awake, with a BP of 130/80, HR of 95-120, RR of 28-30. The patient was seen to have
diarrhea, miotic pupils of 1-2mm, excessive salivation, and bibasal rales. The patient was then referred to this institution by phone call. Atropinization was
started based on the advice of the Toxicology Section. Upon further evaluation, the patient was seen to achieve the goals of atropinization with physical
findings of dilated pupils 3-4mm, decreased salivation, no diarrhea, and normal heart rate. The patient was then transferred to PGH for further evaluation and
management.
ROS: (-) fever, (-) cough, (-) angina, (-) dyspnea, (-) orthopnea, (-) PND, (-) constipation, (+) abdominal pain, (+) nausea and vomiting, (-) melena, (-) weakness, (-)
easy fatigability, (-) weight loss, (-) dysuria, (-) oliguria, (-) loss of consciousness, (-) seizures
Past Medical History: (-) DM, (+) BA (last attack was at 6y.o.), (-) HPN, (-) allergies
Family Medical History: (-) DM, (-)BA, (+) HPN - mother, (+) heart disease – father, (-) CA
Personal and Social History: smokes 6-10 sticks per day since 2008, (+) alcoholic beverage drinker
9.
Physical Examination (Pertinent Findings per System)
General Survey: Patient is awake, intubated, ET size 7.5 at L22
Vital Signs: BP: 100/60 HR: 96 RR: 24 Temp: febrile to touch
HEENT: pink conjunctivae, anicteric sclera, (+) pinpoint pupils, (-) neck vein engorgement, (-) anterior neck mass, (-) cervical lymphadenopathy, (+) relatively dry
buccal mucosa
Chest/Lungs: equal chest expansion, clear breath sounds, (-) rales, (-) wheezes
CVS: AP, AB at 5th ICS LMCL, DHS, tachycardic, regular rhythm, (-) heaves/thrills/murmurs
Abdomen: soft flat abdomen, hypoactive bowel sounds, (-) tenderness, (-) masses
GU (IE): (+) foley catheter
Skin / Extremities: pink nailbeds, full and equal pulses, (-) edema, (-) cyanosis, (-) jaundice, good skin turgor
Neuro Examination: intact sensory, (+) proximal muscle weakness, 4/5 on all extremities
10.
Course in the ER/Wards
Course in the ER
2/13 – The patient was received conscious, coherent, weak, and wheelchair-bound. The patient was evaluated to have essentially normal physical examination findings. DEM’s
assessment was Organophosphate Ingestion, Accidental. CBC, electrolytes (Na, K, Cl, RBS, Crea, BUN, AST, ALT), PT/PTT, blood typing, ABGs, UA, 12-L ECG, and CXR-APL were
requested. External decontamination was done. The patient was hooked to O2 inhalation at 5lpm via face mask. IVF: D5 0.9 NaCl 1L was regulated to run for 8 hours. Atropine
1mg every 15 minutes was given until pupils ≥ 4mm, decreased salivation, heart rate ≥ 60, and hypoactive bowels were noted. The patient was also referred to Toxicology and
the GEN MED Service.
Toxicology’s initial assessment in the ER was Organophosphate Poisoning, Moderate, Accidental (Termite X). Their physical exam revealed that the patient was awake,
coherent, not in distress at that time. VS (BP 100/70, HR 84, RR 24, T afebrile). Pupils were noted to be 2mm EBRTL. Oral mucosa was noted to be moist with minimal salivation
and the bowel sounds were hypoactive. There was also note of tremor and fasciculation and motor incoordination. CBG was noted to be 113 mmol/dL. Toxicology advised
decontamination of the patient (bathe with soap and water and discard all contaminated clothing), O2 at 2-4Lpm via NC, NPO, IVF: D5 NSS 1L x 8h. RBC cholinesterase was also
requested. Therapeutics: Atropine 1mg IV every 15 minutes (12am, 12:15am, 12:30am, 12:45am, 1am), Famotidine 20mg IV every 12h (given at 12am). Patient was hooked to
cardiac monitor.
2/14 (1am) – TOXICOLOGY: Pupils 1-2mm, HR 102, hypoactive bowel sounds, minimal salivation, muscle fasciculation, tremors, and muscle stiffness (esp. jaw) were present. Atropine
1mg IV every 15 minutes was continued, Diazepam 5mg every 8h and atropine nebulization (until salivation decreased) every hour were started. (2am) pupils 2mm HR 110,
decreased salivation, hypoactive bowel sounds, decreased muscle stiffness. Atropine was continued. (3am)pupils 2-3mm, HR 105, dry lips and oral mucosa, hypoactive bowel
sounds. Atropine was decreased at 1mg IV every 30mins, atropine nebulization was continued. (4am) pupils, 3-4mm, HR 109, dry oral mucosa, hypoactive bowel sounds,
decrease in tremors and fasciculations. Atropine 1mg IV every 4 hours, atropine nebulization continued every 2 hours, diazepam was continued. GEN MED (4:30am): atropine
1mg IV every 2h, d/c atropine neb, diazepam 5mg IV q8h. TOXICOLOGY: ¾ atropinization parameters. Noted that Termite X is a Class I pesticide (Organophosphate specifically
chlorpyrifos), LD50 = 150mg/kg, with a 50cc amount of ingested substance, dose ingested is greater than LD50 at 400mg/kg. Atropinization continued as scheduled to maintain
atropinization parameters (HR 60-100bpm, dry buccal mucosa, pupils ≥ 5mm, hypoactive bowel sounds). Diazepam continued and blood typing requested. Pay MHAPOD: Noted
labs which showed hyperleukocytosis with neutrophil predominance. TOXICOLOGY: HR 105, pupils 5mm, hypoactive BS, dry oral mucosa, (+) 2 episodes of watery diarrhea.
Atropinization 1mg IV q1 and 1mg + 1cc pNSS q1 neb. (+) 3 episodes of diarrhea, slight salivation, pupils 2mm, HR 110. WAPOD: noted ¾ parameters met. Atropine q2 IV.
TOXICOLOGY: noted (+) LBM, hypoactive BS, 2mm pupils, slight salivation, CBS. Advised increase in atropine 1mg IV q1, for blood transfusion 1pRBC.
Patient was admitted at Ward 1 Bed 19. A> Organophosphate poisoning, moderate, accidental (Termite X). CXR PA upright, CBC with platelet count, blood typing, RBC
cholinesterase was requested. Atropine 1mg IV q2, atropine nebulization q1, diazepam 5mg SIVP q8 were continued.
2/15 – TOXICOLOGY: hooked to nasal cannula and pulse oximeter. Urine myoglobin, repeat BUN and creatinine were requested. Monitored atropinization parameters revised (HR 60100, pupils > 4mm, hypoactive bowel sounds, dry oral mucosa, NAHCO3 gargle or baking soda, NaHCO3 50 mEqs IV q8 to maintain urine pH ≥ 5. RIC: BP 110/70, HR 116, pupils
2mm, hypoactive bowel sounds, moist oral mucosa. TOXICOLOGY: (+) oral secretions, (+) muscle fasciculations, increase atropine IV every 30 min, atropine neb every 30 min,
diazepam 5mg IV every 8h, patient was intubated. RIC: (+) crackles all over. Patient was started with Ceftazidime 1g TIV and clindamycin 300mg IV every 6 hours. TOXICOLOGY:
noted RBC cholinesterase results showed a 96% depression from the normal value. An increase in Hct was noted. Transfusion of 4 U FFP is needed.
Course in the MICU
2/15 – (8pm) Patient was received awake, intubated at L22 ET 7.5 with BP 100/60, HR 108, RR 24, T afebrile to touch. The patient notably had pinpoint pupils, tachycardia, hypoactive
bowel sounds and moist buccal mucosa. Admitting impression was 1) organophosphate poisoning severe in intermediate syndrome, 2) AKI probably secondary to
rhabdomyolysis, 3) stress hyperglycemia, 4) r/o aspiration pneumonia. Patient was placed on NPO with CBG monitoring every 4 hours (<60 – 1 vial of D5050, <80 – ½ vial of
D5050). IVF: 1) D5 NSS 1L x 6h, 2) pNSS 1L x 12h. Diagnostics: urine myoglobin, urine pH, ABG, repeat CBC, repeat BUN, Crea, K, Ca, alb, CK-Total and post-intubation CXR were
done. Therapeutics: 1) atropine 1mg IV q15, 2) atropine neb q15 with 1 amp + 1cc pNSS, 3) diazepam 5mg IV q8h, 4) NaHCO3 50mg IV q8h (for urine pH <5), 5) Clindamycin
600mg IV q8h, 6) paracetamol 300mg TIV q4h for T > 39degC. Patient was hooked to cardiac monitor. MV settings: AC mode, IFR 60%, BUR 18, PEEP, FiO2 100%, TV 450mL.
Transfuse 4 units FFP LD then 2 units every 12h. The patient was referred to Renal and Neuro.
(11:30pm) – ¾ parameters met (pupils 3mm, dry oral mucosa, hypoactive bowel sounds, (+) reaching hands into air, (+) fasciculations). Atropine was decreased to 1mg
TIV every 30mins. Atropine nebulization was withheld temporarily. Diazepam 5mg TIV now then q8 was continued. Target parameters were continually monitored.
2/16 – (12:15am) A> probable atropine toxicity. HR 112, pupils 3mm, hypoactive bowel sounds, (+) agitation, (+) restless, (+) warm to touch. Atropine was decreased to 1mg TIV every
hour. Noted K of 2.9. 40 mEqs KCl incorporated in 1 L pNSS to run for 8 hrs x 3 cycles was started. Atropine neb 1 mg + 1cc pNSS + 1 cc pNSS pRN for salivation. Famotidine 20mg
TIV q12. (3:30am) – Noted labs: urine pH 6.26, urine myoglobin negative. IVF revised: L) 40 mEqs KCl incorporated in D5NSS 1L x8h for 3 cycles, R) 1L pNSS to run for 12h.
Continue NaHCO3 50 mEqs TIV q8. (5:30am) – still ¾ parameters met (pupils 2-3mm, hyperactive BS, HR 92, dry oral mucosa), atropine continued 1mg IV q1. (8:20am) – ¼
parameters met, atropine 1mg IV q15, atropine neb 1mg + 1cc pNSS q30. (9:50am) – 4/4 parameters met, A> organophosphate poisoning, severe, in intermediate syndrome,
AKI probably secondary to rhabdomyolysis, resolved; stress hyperglycemia, r/o aspiration pneumonia. OF started at 1800 kCal/day. IVF: pNSS 1L KVO + SD of FFP 50cc x 1 hr + 2
more bags and KCl 40mEqs in D5NSS for 8 hours x 8 cycles. Atropine nebulization was withheld. MV settings revised: AC mode, IFR 50, BUR 12, TV 400ml, PEEP 5, FiO2 40%.
(2:30pm) – patient was placed on NPO for high risk of aspiration. Transfuse 1 u pRBC properly typed and crossmatched and 2 u FFP properly typed and crossmatched q12 after
pRBC transfusion. Atropine was adjusted depending on the parameters.
2/17 – (7:00am) – NPO. IVF: pNSS 1L x 12h, D5NSS 1L x8h, d/c KCl incorporation. Tx: 1) atropine 1mg IV q30m, 2) nebulizer with atropine 1mg with 1cc pNSS q30m, 3) diazepam 5mg
TIV q8, 4) famotidine 20mg TIV q12, 5) paracetamol 300 mg TIV q4 for T>39, 6) resume clindamycin 300mg cap q6 per NGT. Atropine was adjusted due to uncontrolled
parameters. Seen by Toxicology. Clindamycin discontinued. Anti-embolic stockings applied, bilateral lower extremities. Bedsore precautions done. (9:00pm) patient seen by
toxicology. Atropinization revised. 1) start atropine drip: 10mg atropine in 90cc pNSS in a soluset to run for 10hours (1mg/hr based on 20% loading dose). 2) revise atropine
boluses to 1mg IV q30m-q1h as needed if 3/5 parameters not being met. Addition of clear breath sounds to parameters. 3) revision of atropine neb to q1 as needed for
bronchorrhea/hypersalivation. Bladder training started. Patient shifted to CONDOM catheter.
2/18 – The patient was seen by neuro. CK-MB, CK-Total requested and advised to proceed with EMG-NCV. Atropine bolus was revised according to parameters met.
2/19 – Atropinization revision: DRIP 1mg/hr (5cc/hr), BOLUS 1mg q1, NEB 1mg in 1cc pNSS q1. (3:30am) referred due to BP 140/90. Furosemide 20mg TIV given. IVF revised: D5NSS 1L
x 16, pNSS 1 L x KVO during BT only and shift to heplock after BT. Oral feeding started per NGT. Give furosemide 40mg TIV now then 40mg every after BT of 1u pRBC or FFP.
EMG-NCV done with normal wet read. (1:30pm) patient extubated, patient can tolerate (HR 101, O2 sats 99%, spontaneous breathing). Revised atropinization: d/c atropine drip.
IV: atropine 1amp TIV q2. Neb: atropine 1amp + 1cc pNSS q1.
2/20- The patient was noted to have several 1 episode of desaturation (85%). Noted to be tachypneic (40s) and with alar flaring and neck vein engorgement
even if on face mask at 10 lpm. There was also note of pooling of secretions. On suctioning, there was note of yellowish loose phlegm. (+) note of
improvement of breath sounds and resolution of rhonchi/crackles with improvement of O2sats to 94-98 % after suctioning. Working impression was ARF
Type 1 secondary to 1. Osbtructive atelectasis probably secondary to mucus plug from bronchorrhea. 2. R/o VAP. Patient was hooked back to MV on SIMV
mode. TV 400 mL, Psupp 8 cm H20, VSUR 12, FiO2 60%. Patient was also started on Ceftazidime 2 g IV q8, Metronidazole 500 mg 1 tab q6 and continued
on other meds, Famotidine 50 mg IV q12, Atropine sulfate 1 mg IV q15 mins, and Atropine nebulization q 30 mins. Nebulization with Salbutamol 1 neb +
1cc NSS q8 & prn was also done. Patient was seen by Pulmo. Assessment was aspiration pneumonia vs new onset VAP. Mech vent settings were revised
to Spont Mode, FiO2 40%, PEEP 5, Psupp 8, Trigger 4 but was eventually revised to AC mode
11. Pertinent Laboratory and Pertinent Diagnostic Findings: (CBC, Urinalysis, Fecalysis, X-ray, Biopsy, etc.)
Blood Type: O+
CBC:
2/14 (2:23am) – Hgb 165, Hct 0.493, Plt 277, WBC 18.7 (Neu 0.841, Lym 0.128, Mo 0.027, Eo 0.001, Ba 0.003)
2/14 (10:01am) – Hgb 174, Hct 0.550, Plt 231, WBC 27.1 (Neu 0.779, Lym 0.169, Mo 0.047, Eo 0.003, Ba 0.002)
2/16 (8:38am) – Hgb 128, Hct 0.387, Plt 197, WBC 13.0 (Neu 0.775, Lym 0.157, Mo 0.064, Eo 0.002, Ba 0.002)
2/17 (1:47am) - Hgb 129, Hct 0.384, Plt 151, WBC 12.4 (Neu 0.752, Lym 0.180, Mo 0.052, Eo 0.013, Ba 0.003)
2/18 (12:10pm) - Hgb 76, Hct 0.278, Plt 150, WBC 4.2 (Neu 0.68, Lym 0.30, Mo 0.02)
2/18 (4:43pm) - Hgb 143, Hct 0.0.428, Plt 140, WBC 8.9 (Neu 0.73, Lym 0.21, Mo 0.01, Eo 0.05, Ba 0)
2/20 Hgb 165 Hct 0.492 Plt 111
CHEM:
2/14 (1:03am) – RBS 6.68 (high), BUN 3.25, Crea 62, AST 28, ALT 35, Na 139, K 3.5, CL 100
2/14 (10:03am) – RBS 11.82 (high), Crea 391(high), Na 141, K 5.3 (high), Cl 105
2/14 (12:17pm) – ALT 694 (high), Mg 1.18 (high), Ph 5.13 (high), CK-Total 4239 (high), CK-MB 283.1 (high)
2/15 (11:20pm) – BUN 3.67, Crea 79, Alb 39, Ca 2.05 (low), CK-Total 150 (high), K 2.9 (low)
2/17 (1:30am) – alb 34, Ca 2.04 (low), Phos 0.75 (low), K 3.7
2/17 (10:00am) – crea 59
2/19 (4:20am) – CK-Total 54 (low), CK-MB 6.8
PT:
2/14 – 11.9 | 12.0 | >1.0 | 1.15
aPTT:
2/14 – 37.0 | 32.9
ABG:
2/14 (1:11am) – 7.366 | pCO2 36.7 | pO2 84.8 | HCO3 21.0 | O2sats 95.9% | BE -3.3
2/14 (9:56pm) – 7.249 | pCO2 51.8| pO2 86.9 | HCO3 22.6 | O2sats 94.7% | BE -4.7
2/15 (3:20pm) – 7.462 | pCO2 28.4| pO2 193.8 | HCO3 20.3 | O2sats 99.4% | BE -1.1
2/16 – 7.486 | 26.5 | 316 | 20.0 | 99.8% | BE -0.8
2/18 – 7.413 | 36.9 | 250.1 | 23.5 | 99.6 | -0.1
2/19 – 7.388 | 40.6 | 93.9 | 24.4 | 97.0% | -0
U/A:
2/14 – yellow, clear, 1.030, 6.5, (-) CHO, 1+ CHON, 0-1 rbc, 5-8 wbc, 0-1 coarse granular casts, rare EC, few bac, (-) MT, (-) crystals, (-) bilirubin, (-) Leukocytes, (-) nitrites, (-) Hgb,
normal urobilinogen, 1+ ketones
2/16 – pH 6.26, myoglobin (-)
2/15 – urine pH 6.26, urine myoglobin (-)
RBC Cholinesterase:
2/15 – 0.027 ∆pH/hr (NV: 0.75 -1.0)
2/16 – 0.02 ∆pH/hr (NV: 0.75 -1.0)
2/17 – 0.07 ∆pH/hr (NV: 0.75 -1.0)
2/19 – 0.06 ∆pH/hr (NV: 0.75 -1.0)
12.
Surgical Operation:
Date: ____________________
(Month/Day/Year)
Time: ____________________ am/pm
Printed Name & Signature of Surgeon
Type of Anesthesia:
Printed Name & Signature of Anesthesiologist
13.
Discharge:
a. Date: _____________ __
(Month/Day/Year)
b. Time: ____________________ am/pm
c. Final Diagnosis: __________________________________________________ __________________________________________________________________________________
d. Condition on Discharge:
____________________
e. Signature of Attending Physician:
14.
Signature or Right Thumbmark of Patient or His/Her Representative:
Printed Name & Signature of Patient or His/Her Representative
Right Thumbmark
(In case patient and representative cannot write)
Printed Name & Signature of Witness to Thumbmark