Medical Abstract

November 5, 2016
General Data:

Patient is LAUREOLA, LORNA ABARY, a 96-year old female who was admitted on August 30, 2016 due to
fever.

History of Present Illness:

needed,
episodes

One day prior to admission, patient developed cough with yellowish sputum accompanied with fever (Tmax
38.8C), colds, and decreased appetite. No dyspnea was noted. Patient was given Paracetamol as
with slight relief. Night prior to admission, private duty nurse noted audible secretions with choking
and persistence of decreased appetite thus this consult.

Review of Systems:

Unremarkable

Past Medical History:

(+) Hypertension for 30 years, highest BP unrecalled, usual BP 120-130 mmHg systolic
(+) Alzheimers disease for 10 years
(+) Chronic Kidney Disease for 10 years, not on hemodialysis; baseline Creatinine 1.1
s/p Right Knee Surgery, (2000s)

Family History:

(+) Hypertension

Personal and Social History: Non-smoker, non-alcoholic beverage drinker

Physical Examination:

Awake, not in distress, denies chest pain, dyspneic

BP = 154/85 mmHg PR = 99 bpm RR = 20 cpm Pain Scale = 0/10 Temperature = 38.8C
Pink palpebral conjunctivae, anicteric sclerae
Symmetrical chest expansion, no presence of lesions or deformity
Bilateral rhonchi
Normal rate, regular rhythm
Soft abdomen, nontender, normoactive bowel sounds
No presence of edema, pulses full and equal

Admitting Impression:

ASPIRATION PNEUMONIA HIGH RISK

Course in the Wards:

Problem 1: Acute Respiratory Failure secondary to Prolonged Mechanical Ventilation

Patient was seen pale, tachypneic, with labored breathing, cyanotic, with harsh breath sounds and
with oxygen saturation of 50% at room air. Patient was intubated. Specimen was sent for endotracheal tube
culture and revealed normal flora growth. Blood CS from 2 sites showed no growth. Patient started on
Salbutamol + Ipratropium nebulization, Budesonide 500 mcg 2 respules via inhalation 1 dose with chest X-ray
showed lungs to be hyperaerated with increased haziness in the right parahilar and paracardiac pulmonary
areas. The patient was started on Piperacillin-Tazobactam 2.25 gm IV given every 6 hours and was given for
14 days. Patient was weaned off mechanical ventilator and was extubated on 2 nd hospital day at 1030H. On
same day, patient was noted to have increased bloody, frothy secretions; thus, patient was reintubated and
hooked to mechanical ventilator. Repeat endotracheal GSCS and Blood CS were requested which showed
Tropicalis and C. Albicans. Weaning was repeatedly done, but it was not tolerated with noted episodes of
apnea.
On the patients 20th hospital day, the patient underwent tracheostomy which was tolerated well.
On the patients 29th hospital day of admission, chest xray was done which showed atelectasis of
the left lung now with almost complete opacification of the left hemithorax. PEEP was increased and chest
physiotherapy was started. On the 30 th hospital day, patient was referred to the service of Physical Medicine
and Rehabilitation and underwent PT once a day at bedside with fall and fracture precautions. Repeat CXR
was done on the 32nd hospital day which showed partial clearing of the opacification of the left hemithorax due
to atelectasis and pleural effusion; ipsilateral shift of the mediastinal structures still noted and there is further
partial resorption of the right pleural effusion. Mechanical ventilation adjustment and care was continued. On
the 44th hospital day, patient was shifted to SIMV with RR16 and FiO2 35; however due to episodes of desaturations, patient
was shifted back to AC mode with the FiO2 at 35%. On the 64 th hospital day patient still had minimal bilateral rales. CPAP
PS 10, Fi02 was at 24% PEEP 5. On the 67th day, Mechanical ventilation setting was put on SIMV mode.
Problem 2: Hospital Acquired Pneumonia

There was note of fever on the 8 th hospital day. Cultures from endotracheal tube showed
Pseudomonas aeruginosa and Klebsiella pneumoniae. Patient started on Meropenem 1 g IV every 12 hours.
On the 35th hospital day, fever episode recurrence noted. Paracetamol was prescribed, CBC was done, and

follow-up of tracheal CS was done; wherein, Imipinem-resistant P. aeruginosa was isolated. Patient was
started on Ceftazidime 1g IV every 12 hours and Colistin 1M units every 8 hours. On the 37th hospital day,
repeat chest X-ray was done which revealed accentuation of the pulmonary vascular markings due to
congestion and minimal clearing of the left pleural effusion. On the 41 st hospital day, repeat chest x-ray
showed partial clearing of the pulmonary congestion with slight increase in the left pleural effusion. On the
48th day hospital day, cultures still had no growth. On the 57th hospital day, patient was noted to be tachypneic,
tachycardic in respiratory alkalosis. Chest xray revealed hazy opacities are seen in both mid to lower lung
fields, secondary to edema. The right costophrenic sulcus is now blunted due to pleural effusion. Minimal
increase in the left pleural effusion is seen. Scan of Chest which revealed ground glass opacities in both
lungs with interspersed subcentimeter ground-glass nodules. These are probably due to an infectious
process. Noted are moderate bilateral pleural effusion with few prominent lymph nodes in the precarinal
region, not pathologically enlarged by cross-sectional imaging criteria with small hypoenhancing nodules and
nodules with calcifications in the right lobe of the thyroid gland, some probably representing cysts. On the 58 th
hospital day, chest ultrasound revealed bilateral pleural effusion, Right lung 213 ml, left lung 213 ml. On his
64th hospital day Patient was still having fever episodes of 38.4 TMAX with loose whitish secretions per ET
tube.

Problem 3: Hypertensive Heart Disease

Patient was referred back to Cardiology service due to Hypertensive Heart Disease. Patient was
seen with sinus tachycardia on cardiac monitor. Patient requested with 2D Echo which showed increased wall
thickness to 0.50, segmental hypokinesia, unchanged aortic valve area (1.44 - 1.5 cm2), moderate tricuspid
regurgitation, increased pulmonary artery pressure increased (41 to 56 mmHg). Patient was started with
Losartan 50 mg/tab daily, Nebivolol 5mg/tab tab daily. Currently, antihypertensives are withheld due to
normotensive BP.
Problem 4: Acute Kidney Injury on top Chronic Kidney Disease
Patient was referred back to Nephrology service. Baseline creatinine was 2.7. There was noted
increasing trend of creatinine, elevated BUN of 128 and progressive anasarca starting September 30, 2016.
Electrolytes were monitored. Daily hemodialysis done as needed. There was improvement in her edema.
Dopamine support of 200mg in 100ml D5W was given at 3mcg/kg/min while on dialysis. On the 42 nd hospital
day, 1u PRBC was transfused during the last hour of hemodialysis. Serum Potassium was noted to be slightly
decreased at 3.3, patient was given potassium chloride 10% solution in 20ml every 4 hours for two doses. On
the 61st hospital day, patient is noted to have edematous extremeties, chest xray was requested which
revealed partial resolution of pulmonary congestion. Partial clearing of the opacities in both mid to lower lung
fields is also appreciated. No new parenchymal infiltrates are noted. Both costrophrenic sulci remain blunted
due to minimal pleural effusion. On his 64th hospital day Hemodialysis was ongoing, there was still noted
edema and bilateral rales heard over the lungs. Dialysis was well tolerated. Vancomycin 1 gram IV was given,
ciprofloxacin 400mg IV every 24 hours post hemodialysis given all dialysis days. On the 66 th day patients
hemoglobin was at 8.4, Hematocrit was at 26, WBC was at 23, 1 unit PRBC was transfused. On the 67 th day
patient was ongoing hemodialysis when there was noted tachycardia 150s-190s, paroxysmal atrial fibrillation
in RVR then SVT , Amiodarone 150mg in 100ml PNSS to run for 30 minutes then 600mg in 250ml D5W to run
for 24 hours.
Problem 5: Lower GI Bleed secondary to Angiodysplasia
Patient had episodes of hematochezia with noted hypotension on the 8 th hospital day (Sep 7).
Patient was transfused with packed RBC. On the patients 9th hospital day, Patient was noted to have blood
per diaper change approximately 300 ml clotted blood. Patient had CBC done which showed, Hemoglobin of
6.7 g/L, Hematocrit of 20.6 and RBC of 2.26 suggestive of Iron deficiency anemia secondary to blood loss.
Tranexamic acid 500 mg IV every 8 hours was started and packed RBC was transfused. She was referred to
GI service for gastrointestinal bleeding. However, initially relatives opted to undergo supportive treatment and
blood transfusion. However due to increased amount of blood transfusion and persistent hematochezia, they
opted active management. Tagged RBC scanning results showed positive bleeding in the sigmoid colon.
On the patients 25th hospital day (Sep 24), the patient underwent Colonoscopy but no active
bleeding was noted. The patient underwent mesenteric angiogram with coiling of angiodysplasia in the
sigmoid artery the next day. The procedure was tolerated well by the patient. There was no recurrence of
hematochezia post-operatively.
On the 37th hospital day, PEG insertion was done which the patient tolerated well started feeding
per PEG. 1440 kcal 1.8CAL/ML divided into 6 equal feedings. 75ml of D5W flushes were also administered
every 4 hours.
On the 57th day and 58th hospital day, CBC results showed low hemoglobin but with no gross
bleeding except for blood tinged trache secretion. Patient was transfused with 2 units of pRBC and had CT
scan of the abdomen which revealed small hepatic cyst (segment 7/8); Mildly atrophic left kidney; Left renal
cysts (Bosniak I); Subcutaneous edema in the abdominal walls; Atherosclerotic disease of the aorta and
coronary arteries and Thoracolumbar spondylosis.

Problem 6: Central Line-Associated Bloodstream Infection

On 18th hospital day (Sep 17), patient was noted to have febrile episode with highest temperature
0
of 39.4 C. The IJ catheter tip sent for culture and showed Candida tropicalis. IJ catheter was transferred to
the left IJ vein. Patient was started empirically on Anidulafungin 100 mg IV once a day. Blood culture showed
Candida tropicalis and urine culture showed Candida albicans respectively. Antifungal shifted to Fluconazole
200 mg IV once a day.
On the 26th hospital day (Sep 25), blood cultures showed negative for fungi. Fluconazole was
continued for 14 days more then discontinued. Gram negative rods grew on blood cultures and so the patient
was started on Levofloxacin 750 mg IV given every 48 hours and Meropenem 500mg IV. Blood culture
revealed Burkholderia cepacia which was noted to be resistant to Ciprofloxacin but was Sensitive to
Cotrimoxazole and Meropenem, thus Levofloxacin was shifted to Cotrimoxazole 400 mg/80 mg given via IV
route every 8 hours. The patients IJ catheter was also replaced and reinserted in the right Jugular Vein by
Vascular Surgery service. Patient clinically improved. On the patients 35 th hospital day (Oct 4), patient had
febrile episodes. Central line CS showed gram negative rods showing Elizabethkingia meningoseptica. Patient
was started on Ceftazidime 1g IV every 12 hours and Colistin 1M units every 8 hours. On the 41 st hospital day,
IJ catheter blood CS was requested which showed no growth after 48 hours.
On the 53rd hospital day, patient was febrile with a maximum temperature of 37.8 degrees Celsius. Ij catheter
tip Blood CS on 1 site was done which showed oxacillin resistant S. epidermidis, sensitive to
trimethoprim/sulfamethoxazole, vancomycin and linezolid. On the 55 th hospital day, blood culture showed no
growth for 5 days, thus foley catheter was removed. On the 63th hospital day blood culture and sensitivity
were done. Vancomycin 1 gram IV infused for 2 hours given, ciprofloxacin 400mg IV every 24 hours post
hemodialysis given all dialysis days. On the 65th day patient was stupurous with no movement of extremeties
and was assessed with septic metabolic encephalopathy. On the 66 th day Micufungin 100mg IV was started
then 50mg IV every 24 hours for yeast isolates, assessment is now sepsis probably secondary to fungemia.
Problem 7: Hyperglycemia
Patients CBG was continuously monitored, on his 64th hospital day patient was referred to
endocrinology for management of hyperglycemia, Hydrocortisone 50mg IV was given every 6 hours. CBG was
requested every hour during dialysis, glulisine was given subcutaneously. CBG was measured and insulin was
titrated accordingly. Nephro diet at 1700kcal was ordered. On the 67th day CBG post dialysis was at 240,
insulin glargine 10 units was given subcutaneously and insulin glulisine 5 units given. Hydrocortisone was
decreased to 25mgIV every 8 hours.
At the 67th day, Patient was noted to have irregularities in ECG, noted torsades on strip eventually turned into
coarse ventricular fibrillation, PEA runs, hypotension then idioventricular rhythm. Mechanical ventilator is put
on SIMV is on DNR status, No defibrillation, No CPR done. Official time of death 1838H, post Mortem care
rendered. Cause of death is
FINAL DIAGNOSIS: CARDIAC ARREST SECONDARY TO CARDIAC ARRHYTHMIA, SEPTIC SHOCK SECONDARY TO
FUNGEMIA.SEPSIS; LOWER GI BLEED secondary to ANGIODYSPLASIA, CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION,
HOSPITAL ACQUIRED PNEUMONIA; S/P INTUBATION (8/29); EXTUBATION (8/31); RE-INTUBATION (8/31); ANEMIA SEC TO
HYPOVOLEMIA; S/P CL INSERTION (9/8); CENTRAL LINE REINSERTION (9/18); S/P TRACHEOSTOMY TUBE INSERTION (9/19),
ACUTE KIDNEY INJURY ON TOP OF CKD ON HD; SEPTIC METABOLIC ENCEPHALOPATHY ON TOP OF NEUROCOGNITIVE
DISORDER; S/P BEDSIDE COLONOSCOPY (9/23); S/P MESENTERIC ANGIOGRAM W/COILING (9/24); S/P CENTRAL LINE
REINSERTION (9/26); S/P CL RETHREADING RIGHT S/P CENTRAL LINE REINSERTION(9/30), S/P PEG INSERTION 10/7, SEVERE
DEMENTIA; 10/7 S/P EGD & PEG INSERTION; S/P TUNNELED DIALYSIS CATHETER, RIGHT; 10/21 PERMCATHETER AND L IJ
CATHETER REMOVAL

Prepared by:
_____________________
Physician in Charge
Department of Internal Medicine
Makati Medical Center