General Information NF 2 months/female Filipino Roman Catholic Sapang Palay, Bulacan DOB: July...
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Transcript of General Information NF 2 months/female Filipino Roman Catholic Sapang Palay, Bulacan DOB: July...
General Information
NF 2 months/female Filipino Roman Catholic Sapang Palay, Bulacan DOB: July 1, 2014 DOA: September 6, 2014
CHIEF COMPLAINT
Fecaloid discharge
from post-op site
History of Present Illness
Diagnosed case of Gastroschisis Admitted at our NICU from July 2014 to August 20,
2014, discharged apparently well, with weight of 2.2 kg, fed with purchased EBM from milk bank
Seen at the Neonatology OPD 7 days PTA, advised admission due to dehydration; admitted for 1 day at our ER and discharged apparently well
1 day PTA, mother noted fecaloid material coming out from post-operative site
Persistence prompted consult to our ER
History of Present Illness
10 hours prior to
admission
• Fever, Tmax: 38.2 ˚C• Fecaloid material from post-op site•No cough, colds, no vomiting•No bowel movement, last BM was 1 day PTA• Poor suck and activity•No consult done•No meds given
History of Present Illness
two hours PTA
• Post-op wound with surrounding erythema, which continuously draining fecaloid discharge• (+) fever•Poor suck and activityADMISSION
Review of Systems
General: poor weight gain HEENT: No ear discharge, no colds, good suck Cardiac: No cyanosis when feeding GI: (+) changes in the consistency of the stools GU: no decrease in urine output, no changes in the
color of urine Hematologic: No pallor, occasional and minimal
bleeding on the lesions on the inguinal area Musculoskeletal: No muscle weakness, no joint
swelling Neurologic: No seizures
Birth and Maternal history
Born to a 18 y/o G2P2 (2002), nonsmoker, nonalcoholic beverage drinker.
regular PNCU since 2 months AOG at a LHC, attended by a midwife.
with intake of MVS, FeSO4 UTZ at 5 months AOG, (+) protruding
mass over umbilicus No maternal illness noted No Congenital Scan
Birth and Maternal History
Delivered full-term, via NSD at Sapang Palay District Hospital c/o midwife, with good cry and activity
(+) abdominal wall defect with gastric contents protruding, lateral to the umbilicus
Given Erythromycin ointment, OGT inserted, gastric contents wrapped in a gauze soaked in PNSS, advised THOC to PCMC
Admitted at the Neonatal ICU for 1 1/2 months
Family History
29 30
2mos
No history of Hypertension, DM, Bronchial Asthma, Allergy, Malignancy, Seizure disorder
2 y/o
Immunization History
BCG x 1 dose Hep B x 1 dose
Nutritional History
Started on EBM at birth fed through OGT, shifted to formula feeding Bona 1:2 dilution, 4oz q4
No residuals. No swallowing difficulties
Developmental History
Gross motor Poor head control
Fine motor fisting
Language coos
Personal Social No social smile
Personal Social History
Lives in a well lit, well ventilated house with extended family on the paternal side, together with 7 household members
Primary caregiver: Mother Source of water: tap water Garbage collected twice a week House not near factories and highways
Past Medical History
Previously admitted at our NICU: last July 3, 2014 to August 18, 2014 due to Gastroschisis, s/p emergency application of IV bag, s/p abdominal wall closure using MESH 7/25/2014, Sepsis (Candida), resolved; AKI due to Sepsis, resolved; SSI (p. Aeruginosa), resolved
Readmission last August 28, 2014 due to AGE, admitted for 1 day at our ER
Physical Examination on Admission General Survey: awake, not in
respiratory distress Wt: 2.0 kg (z score: <-2 ) VS:
Temp 36.0 CR 122 RR: 41
Physical examination
Skin: no jaundice, no cyanosis HEENT: No skull deformities, (+) sunken
fontanels, anicteric sclerae, (+) pale palpebral conjunctiva, no eye discharge, (-) ear discharge, no alar flaring, moist lips and tongue, no buccal mucosal lesions, no tonsillopharyngeal congestion
Chest: symmetric chest expansion, shallow subcostal and intercostal retractions, clear breath sounds
Physical examination
Heart: adynamic precordium, no heaves, thrills or lifts, normal, regular rhythm, no murmurs
Abdomen: globular abdomen, normoactive bowel sounds, (+) fecaloid material from post-operative site, greenish pasty output approximately 10ml
Extremities: Faint pulses, cold extremities, no cyanosis, no edema, CRT <2 secs
Neurologic exam: intact cranial nerves, spontaneous movement of both extremities, normoreflexive, no nuchal rigidity, no nystagmus
Admitting Diagnosis at the Wards
Gastroschisis, s/p Abdominal Wall Closure using
MESH (7/25/2014), Sepsis,
Healthcare-Acquired Infection
Course in the Wards
Course in the wards 1st HD
S/O P
6:00 AMSeen by Surgery at ER
8:00 AMWeak looking, sunken fontanels, sunken eyeballs(+) fecaloid material over post-op site
Cbc:Hgb: 67Hct: 20WBC: 22Segmenters: 70Lymph: 26Mono: 4Platelets: 218• Wound GS,
CS• Blood CS
Admit to Surgery WardNPOD5LR mild for 6 hoursPLR vol/vol
replacementPRBC (10ml/kg/aliq) x
3Therapeutics• Refer to PIDS for
Meropenem (60)• Insert OGT, cutdown• Refer to Gastro
Service for comanagement
Course in the wards 2nd HD
S/O P
AwakeNot in distressFlat fontanelsPink conjunctiva, anicteric sclerae, isocoric pupils(+) fecaloid material approximately 20mlFull and equal pulsesUO 5.1ml/kg/hr
• Wound GS, CS
• Blood CSPost PRBC Cbc:Hgb: 142Hct: 42WBC: 19.6Segmenters: 64Lymph: 33Platelets: 163
NPOD5IMB (Mtn)PLR vol/vol
replacements/p PRBC
(10ml/kg/aliq) x 3Therapeutics• Meropenem (60)• Mupirocin ointment
on affected areas• Updated Gastro
Service, for formal referral
Course in the wards 3rd HD
S/O P
AwakeNot in distressFlat fontanelsPink conjunctiva, anicteric sclerae, isocoric pupils(+) fistula output 30mlFull and equal pulsesUO 3.4ml/kg/hr(+) hypoglycemic episodes, s/p 2 doses of D10W (5) IV bolus
• Wound GS, CS
• Blood CS
For Emergency Removal of MESH
Standby 1 u PRBC for OR use
GASTRO: Ideally to start TPN, however without funds hence maintained on D7.5IMB
Course in the wards 4th HD
S/O P
AwakeNot in distressFlat fontanelsPink conjunctiva, anicteric sclerae, isocoric pupils(+) fecaloid material approximately 30mlFull and equal pulsesFB +309UO 12.2 ml/kg/hr(+) hypoglycemic episodes, s/p 2 doses of D10W (5) IV bolus
Awaiting funds for• Wound CS• Blood CSPost PRBC Cbc:Hgb: 119Hct: 35WBC: 12Segmenters: 61Lymph: 28Monocytes: 11Platelets: 140Urine KOHNBS
s/p removal of MESH, post-op Day 1
NPONo funds for TPN;
D10IMB (mtn)PLR vol/vol
replacement• Meropenem (60)• Referred back to
PIDS for possible use of Fluconazole, continue Meropenem
GASTRO: Facilitate TPN, suggest rectal stimulation
Course in the wards 5th HD
S/O P
AwakeNot in distressFlat fontanelsPink conjunctiva, anicteric sclerae, isocoric pupilsIntact post-op dressing, no fecaloid materialFull and equal pulsesUO 13.4 ml/kg/hr(+) hypoglycemic episodes, s/p 2 doses of D10W (5) IV bolus
Awaiting funds for• Wound CS• Blood CS
s/p removal of MESH, post-op Day 2
NPONo funds for TPN;
D12.5IMB (mtn)PLR vol/vol
replacement• Meropenem (60)• Referred back to
PIDS for possible use of Fluconazole, continue Meropenem
GASTRO: Facilitate TPN, rectal stimulation
Course in the wards 6th-7th HDS/O P
AwakeNot in distressFlat fontanelsPink conjunctiva, anicteric sclerae, isocoric pupilsIntact post-op dressing, no fecaloid materialFull and equal pulsesFB -25UO 10.4 ml/kg/hr(+) hypoglycemic episodes, s/p 2 doses of D10W (5) IV bolus
Awaiting funds for• Wound CS• Blood CS
Electrolytes:Na 142, K 4.9, Cl 116, Ca 2.33
s/p removal of MESH, post-op Day 2
Start Milk Formula 5cc q6 via OGT
No funds for TPN; D12.5IMB (mtn)
PLR vol/vol replacement
Meropenem Day 6GASTRO: Facilitate TPN, rectal stimulation
Course in the wards 8th HD
S/O P
(+) hypoglycemic episodes, s/p 2 doses of D10W (5) IV bolus(+) septic shock
CBCElectrolytesPTAPTTRandom urine sodium
post-op Day 4O2 at 10LPM
Referred to ICUMeropenem Day 8, with missed dosesReferred back to PIDS for Fluconazole use-Started on Ciprofloxacin, Metronidazole, Amphotericin, Vancomycin
Course in the wards 9th HDS/O P
11:00AmAsleep, but arousable(+) still with episodes of hypothermia and hypoglycemia(+) abdominal distentionHypoactive bowel sounds(+) bleeding on previous extraction site
A: Septic shock, T/C DIC secondary to Sepsis
PT 15.2, 11.2, 56.6, 1.36APTT 43.9, 27.5
PNSS at 20cc/kgFor PRBCFor FFPContinue IV antibioticsCipro d2Metro d2Ampho d2Vanco d2Keep thermoregulated For Serum electrolytes
Course in the wards 10th HDS/O P
10:00pmDrowsy, but arousableCR: 90 RR: 30 O2 sat: 93% Temp 34 36.5C(-)alar flaringShallow subcostal retractions and intercostal retractionsClear breath soundsGlobular abdomen, hypoactive bowel sounds, Soft abdomenFair pulses, cold extremities(+) bleeding on previous IV sitesCRT <2 secsPupils 2-3 EBRTL
A> Sepsis, HCAI
ThermoregulatedHook to cardiac monitorHook to O2 at 10LPMKeep thermoregulatedFor Chest xray to include abdomenFor ABGStill for blood CS, serum elec, PT, PTT
For intubation (Appraised parents)
Course in the wardsS/O P
11:25 pmPupils Sluggishly reactive to light
Pupils anisocoric, Gasping, CR: 80sPoor Pulses, cold ext
BP: 0CR: 30-40, gasping , T:34Cpoor pulsesCRT 3 secondsCold ext
For intubation
Start High Quality CPRPNSS (20cc/kg) BolusGive Epi (1:10,000) 0.19 cc IVICU updated
Course in the wardsS/O P
11:25 pmBP: 0 CR: 0, RR: 0 , T:35CRT: 3-4 secondsPoor pulses, cold ext
9/17/201412:00 AMDilated pupilsCR: 0 RR: 0 No pulses
Continue High quality CPRGive another PNSS (20cc/kg) BolusGive Epi (1:10,000) 0.19 cc IV x 6 doses every 2 minutes
Pronounced deadRender post mortem careAutopsy offered but refused
Final Diagnosis
Septic Shock Disseminated Intravascular Coagulation Healthcare Acquired Infection Failure to thrive