Morbidity and mortality 2011
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Transcript of Morbidity and mortality 2011
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!!!