MORBIDITY AND MORTALITYAUGUST 2011

Department of Family and Community Medicine

Perpetual Succour Hospital

TOTAL HOSPITAL ADMISSIONS---

Internal Medicine 46.0% Pediatrics 17.7% Obstetrics & Gynecology

13.0% Family Medicine 11.8% Surgery 11.3%

FAMILY MEDICINE CENSUS152 Adult Medicine 56% Pediatrics 24% Surgery 14% Obstetrics & Gynecology 6%

Outpatient Cases 243 Charity Cases

03 House Cases 11 Mortality case 01

Community OPD Census

47

CO-MANAGED CASES*

Internal Medicine 29 Pediatrics 5 Surgery Obstetrics & Gynecology 9

LEADING CAUSES OF MORBIDITIES IN FAMILY MEDICINE (ADULTS)

1. Acute Gastroenteritis with Some Dehydration 08

2. Community Acquired Pneumonia, Moderate Risk 083. Urinary Tract Infection

08

HEENT 5

Acute Exudative Tonsillitis 3With Urinary Tract Infection 1With Systemic Viral Infection 1

Recurrent Tonsillitis With Drug-induced Gastritis and Esophagitis sp UGIE 1

Maxillary Sinusitis; Dyslipidemia 1

RESPIRATORY 14

Bronchial Asthma In Acute Exacerbation2

RESPIRATORY 14

Community Acquired Pneumonia Moderate Risk 8

With Atrial Septal Defect 1 With DM2; Dyslipidemia 1

Pulmonary tuberculosis 4

With Dyslipidemia; Hypertension 1 With Cholelithiasis 1 With sp CVD Infarct Left MCA 1

RESPIRATORY 14

Sepsis 2nd Lung Abscess with Empyema Thoracis Right; sp Thoracentesis; sp CTT; DM Type 2; Complicated Urinary Tract

Infection 1

Sepsis 2nd Community Acquired Pneumonia; Chronic Kidney Disease 2nd Hypertensive Nephropathy; Anemia 2nd Chronic Kidney

Disease sp Hemodialysis1

RESPIRATORY 14

Upper Respiratory Tract Infection3

With Costochondritis 1 With Hepatitis B infection; UTI

1

CARDIOVASCULAR9 Acute Coronary Syndrome, NSTEMI; Dyslipidemia; HCVD

1

Coronary Artery Disease2

HCVD; DM2; S/P Coronary Angiogram 1

HCVD; BPH 1

CARDIOVASCULAR 9 Deep Venous Insufficiency; HCVD;

Dyslipidemia; Lumbar Radiculopathy L4-L5 1

Hypertensive Urgency 5With Benign Prostatic Hyperplasia 1With Dyslipidemia 2With HCVD 2

GASTROENTEROLOGY18Acute Gastroenteritis With Moderate Dehydration 8

With Acute Kidney Injury 2nd Dehydration on top of Chronic Kidney Injury 2nd Hypertensive

Nephropathy; Hypertension Stage 2; Urinary Tract Infection; Dyslipidemia 1 With Hypertension Stage 2 1 With Community Acquired Pneumonia MR; HCVD1

GASTROENTEROLOGY18

Non Ulcer Dyspepsia1

Acute Calculous Cholecystitis4

With DM2; HCVD 2 With Hepatitis A Infection

1

GASTROENTEROLOGY18Cholelithiasis; VHD-Mitral Regurgitation Mild; Adenomyoma W/ Adenomyosis; Multiple Myoma 1

Gastric Ulcer, Antrum sp UGI Endoscopy 1

Multiple Diverticulosis With Diverticulitis; Colonic Polyps(Transverse Colon); Internal Hemorrhoids sp Colonoscopy; cystocoele 1

GASTROENTEROLOGY 18

UGIB 2nd Erosive Gastritis And Duodenal Ulcer sp UGIE; HCVD; DM2 1

Non-ulcer Dyspepsia; Benign Prostatic Hyperplasia; HCVD; Renal Cortical Cyst Right; Dyslipidemia

1

NEPHROLOGY11 Anemia 2nd Chronic Kidney Disease 2nd

Chronic Glomerulonephritis sp IJ Catheter insertion; S/P AV fistula creation

1

Chronic Kidney Disease 2nd Obstructive Uropathy 2nd Tuberculous Cystitis; Dessiminated Tuberculosis (Pott’s Disease) 1

NEPHROLOGY11Complicated Urinary tract infection 8

with DM type 2 1with DM type 2; Hypertension Stage 2 1with Cholelithiasis; Gastritis; DM2;

Hypertension Stage 1 1with Nephrolithiasis, Right 1with Nephrolithiasis, Left 1

INFECTIOUS DISEASE10Classical Dengue Fever 5

With Acute Exudative Tonsillitis 2With Benign Prostatic Hyperplasia; GERD 1

Dengue Hemorrhagic Fever 1Enteric Fever; Ethmoidal Sinusitis Left

1Measles; Acute Tonsillopharyngitis 1Viral Exanthem 2 With Renal Cyst,Left 1

NEUROLOGY4Acute Cerebrovascular Disease Infarct 3

Right Lentiform Nucleus with HCVD; DM2 1

Right Frontal, Right Caudate, Right Lentiform, Both Thalami, Right Internal Capsule

And Pons With BPH; HCVD 1

Left Lenticulocapsular Area And Left Corona Radiata 1

NEUROLOGY4

Acute CVD Hemorrhage Left Thalamo- Capsular Area Right; HCVD

1

ONCOLOGY 3

Invasive Ductal Carcinoma left Breast Stage IV (Lung and Bone Metastasis) sp MRM(2002) & sp Chemotherapy (March2011) 1

Adenocarcinoma Right Lung St IV (Bone Metastasis) 1

Squamous Cell Carcinoma Tongue Stage IV sp Chemotherapy 1

MUSCULOSKELETAL 6

Diabetic Foot Left with DM2; HCVD 1 Diabetic Foot Right; DM2 1

MUSCULOSKELETAL 6 Lumbosacral Radiculopathy 2nd

Diffuse Disc Bulge At L5-S1; Bilateral Carpal Tunnel Syndrome; Dyslipidemia; Overactive Bladder 2nd Perineural Cyst S2 Area 1

Lumbar Radiculopathy 2nd Disc bulge L1-L2 1

MUSCULOSKELETAL 6

Lumbosacral Radiculopathy sec to disc dessication L5-S1 1

Lumbosacral Radiculopathy sec to L4-L5, L5-S1 disc bulge

1

IMMUNOLOGY 1

Anemia 2nd Systemic Lupus Erythematosus; SLE; PU 26wks AOG NIL 1

MORTALITY 1

M.G. 50/F, Lilo-an Chief Complaint: dyspnea. Final Diagnosis: Invasive Ductal Carcinoma Left Breast Stage IV

(with lung and bone metastases)Date admitted: July 29, 2011Date expired: August 5, 2011No. of hospital days: 7

TAKE OFF CASE

Patient Profile M. F. 60/M, Filipino, Roman Catholic, Paknaan,

Mandaue City

Social/Past Medical History Smoker for >50 pack years, occasional

alcoholic beverage drinker (-) Food and Drug Allergies Previous Hospitalization: July 2011, PSH-

Pneumonia

Chief Complaint: Dyspnea

History of Present Illness 9 days PTA – discharged with a diagnosis of

CAP moderate risk. 4 hours PTA – noted onset of dyspnea on

exertion and backpain. 2 hrs PTA – fever and dyspnea

PHYSICAL EXAMINATION

V/S: BP110/50, PR 108, RR27, T38.9 Skin: no lesions, warm, senile turgor HEENT: pinkish palpebral conjunctiva,

anicteric sclerae, (+) alar flaring, (-) neck vein engorgement

C/L: Equal Chest Expansion, Decreased Tactile

Fremitus Right, Decreased Breath Sounds

Right Lung, (+) Rales Left Lung CVS: Tachycardic, Distinct Heart

Sounds, (-) Murmurs

Abdomen: flat, normoactive bowels sounds,

(-) tenderness GUT: (-) kidney punch sign, bilateral Extremities: (-) edema, strong pulses, (-) deformities

WORKING DIAGNOSIS

CAP MR with Pleural Effusion Right Diabetes Mellitus type 2

ON ADMISSION

O2 at 2LPM IVF was started at 20gtts/min. The following labs were taken.

ON ADMISSIONLabs: Urinalysis

Glucose ++

Protein +

Ketones +

RBC 10-20

WBC 5-10

Epith cells rare

Mucus threads

rare

Bacteria few

CBC

WBC 39.89

HGB 10.6

HCT 31.9

Platelet 691

Neutrophils 96

Lymphocytes

2

Monocyte 2

ON ADMISSION

ECG CXR Xray Lateral decubitus

Sinus Rhythm, Non-specific ST-T wave changes

Pleural Effusion, Right-----

Pleural Effusion, Right-------

Medications: Salbutamol + Ipratropium nebulization,

Paracetamol PO, Ranitidine IV, Meropenem IV, Clindamycin IV, Metformin, Gliclazide, NaCl tab, Erdosteine.

Co-managed with a Pulmonologist

Other Labs:

K 4.47

Na 121

Sputum AFB (3x)

Negative

1ST HOSPITAL DAY

S: (+) Dyspnea, (+) feverO: BP110/80-120/80, PR108-112, RR24-27, T37.5-38.9, O2 Sat 89-91% C/L: Equal Chest Expansion, decreased breath sounds at the R lung field, (+) rales CVS: distinct heart sounds, tachycardic, regular rhythm

UTZ of Hemithorax (Marked and estimated): Axillary: 767 cc (5cm depth) Posterior: 697 cc (5cm depth) No existence of fibrous bands nor

loculations Impression: Pleural effusion Right

Clotting time 10 mins

Protime C13/ p 15.1/ % activity 75%/ INR 1.21

Bleeding time 1 min

Blood type A+

CBS 159-201mg/dL

Thoracentesis was done (450cc of foul-smelling, purulent pleural fluid)

Biopsy of pleural fluid: adequate cellularity, abundant erythrocytes and moderate lymphocytes. No tumor cells demonstrated.

Sputum Gram stain showed Candida albicans

Blood Culture (2 diff sites): no growth after 5 days of incubation.

Rpt CXR: Pleural effusion, Right

A: Empyema Thoracis Right Lung 2nd Lung Abscess; DM2

P: Medications:Meropenem IV, Ranitidine IV,

Salbutamol+Ipratropium nebulization q6h, Metformin 500mg BID, Diamicron30mg OD

Clindamycin 300mg IV Erdosteine 300mgPO BIDParacetamol PO RTC.

O2 inhalation @4LPMReferred to Cardiothoracic Surgeon for CTT.

2ND HOSPITAL DAYS

S: (+) Dyspnea, (+) febrile episodesO: V/S BP 110/70 – 120/80, PR 98-110, RR 21-26, T 37.4 – 37.8, O2 sat 88- 92%C/L: equal chest expansion, (+) ralesCVS: distinct heart sounds, Tachycardic

CBS: 257-265mg/dl CTT was done: drained 800cc of

purulent, foul-smelling fluid. Rpt CXR: Resolving Right Pleural

Effusion; Pulmonary Congestion; Concomittant Pneumonia is considered.; Right CTT in place: Subcutaneous Emphysema Right;

Pleural fluid cytology: Mixed acute and chronic inflammation

Pleural fluid cell block: adequate cellularity, abundant erythrocytes and moderate lymphocytes

A: Empyema thoracis secondary to Lung Abscess sp Thoracentesis, sp CTT

P: Medications: Salbutamol + Ipratropium nebulization q8hrs Paracetamol PO PRN, Ranitidine IV, Meropenem IV, Clindamycin IV, Metformin, Gliclazide, NaCl tab, Erdosteine. Tramadol +Paracetamol tablet 1 tab q 6hrs RTCIncentive spirometry

3RD – 6TH DAY OF HOSPITALIZATION

S: (-) dyspnea, (+) febrile episodesO: BP 120/80- 140/70, PR 102-112, RR21-24, T 36.8- 37.9, O2 sat 90-94%; noted yellowish to bloody CTT drain.

FBS 125.77mg/dL

Na 132

K 3.99

CBS 102 – 168mg/dL

RPT CXR: Resolving Right Pleural effusion; Resolving Pulmonary congestion; concomittant pneumonia still considered; Right CTT in place; Resolved subcutaneous emphysema Right.

2DED: 63% Concentric LV Remodelling W/ Adequate Contractility And Systolic Function But W/ Doppler Evidence Of Diastolic Dysfunction Grade 2.

A: Sepsis 2nd Lung Abscess w/ Empyema Thoracis and Pulmonary Congestion sp Thoracentesis; sp CTT

P: Furosemide 40mg IVTT 2 doses were given. Clindamycin IV was shifted to Clindamycin 300mg 1 cap q6hrs po.

Other meds continued: Salbutamol + Ipratropium nebulization

q12h PRN, Paracetamol PO, Meropenem IV, Metformin, Gliclazide,

NaCl tab, Erdosteine. Tramadol +Paracetamol tablet 1 tab q 6hrs

RTC Conzace 1 capsule OD PO Continue incentive spirometry

7TH – 10TH HOSPITAL DAY

S: (-) dyspnea, (-) febrile episodesO: BP 130/80, PR 82-88, RR 21-23, T 36 36.2, O2 sat 94-95%;

<100cc of pleural fluid/day. PPD test: negative after 48-72hrs Pleural fluid anaerobic culture: Anaerobic

Streptococcus CBS: 90 – 168mg/dL

A: Resolving Pleural Effusion Right; Resolving Pulmonary Congestion

P: IVF terminated and changed to heplock; Decreased O2 inhalation at 2LPM then

discontinued. Clindamycin PO was increased to 300mg 2

caps q6hrs; Paracetamol+tramadol tablets was dec to q8 PRN Last dose of NaCL tablet was given.

Other meds were continued.

Chest tube was removed.

10TH HOSPITAL DAY

S: (-) dyspnea, (-) feverO: BP 120/70- 140/80, PR 78-96, RR 20-23, T 36.0-36.2.

CBS: 136mg/dLA: StableP: patient was discharged w/ home meds:

Metformin 850mg BID PO pc mealsGliclazide 30mg OD PO ac BreakfastConzace 1 capsule OD PO

Home meds: Meropenem 1g heplock for 5 days to

complete 2 weeks then shift to Co-amox 625mg tab TID PO for 6 weeks

Clindamycin 300mg 2 capsules TID x 5 weeks to complete 6 weeks

FINAL DIAGNOSIS

1. Sepsis secondary to Lung Abscess w/ Empyema Thoracis Right; S/P Thoracentesis, Right, S/P CTT, Lysis of loculations, Pleural lavage, Right under fluoroscopic Guidance

2. Diabetes Mellitus type 2

THANK YOU!!!