Emergency pediatric – PICU division Pediatric Department ...
PICU AUDIT
description
Transcript of PICU AUDIT
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PICU AUDIT
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Objectives
• To present a new approach of management of dengue fever
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General Data
• LN• 2 year old• Female• 15.2 kg• February 27, 2012• Malaysian• Hindhu• Lives in Malaysia• Admitted last May 16, 2014
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Chief Complaint
• Fever
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History of Present Illness
11 days PTA
• Undocumented fever– Paracetamol – 1 day
• No other symptoms• No consult done
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History of Present Illness
10 days PTA
• Fever resolved• Good appetite• Good activity
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History of Present Illness
7 days PTA
• Fever Tmax 39• Consult in Malaysia– Serial CBCPC
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LaboratoriesHg Hc WBC Neu Lym Mon
oEo Baso Plt
5/9 13.5 40 2.8 19 70 8 2 121 Atyp lym 1
5/10 12.9 39 2.1 28 58 10 3 1 137
5/11 10.9 35 2.7 18 68 10 3 1 106
5/12 13.2 41 3.6 14 70 11 4 1 139
Na K Cl Phos Ca Corrected Ca
5/9 134 4.2 99 1.69 2.23 2.27
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LaboratoriesUrea Uric
acidGlucose
Crea
5/9 4.8 0.21 4.8 30 EGFR >90
TP A G A/G
5/9 65 38 27 1.41
Total bil
Total chol
ALP GGT AST ALT
5/9 2.8 3.9 181 16 47 33
DNS1 DB Mycoplasma Pneumonia antibody
5/9 Neg Neg 1:40 <1:40
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History of Present Illness
4 days PTA
• Patient discharged• A> Viral Infection• Given Azithromycin
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History of Present Illness
3 days PTA
• Afebrile• Playful• Active
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History of Present Illness
Morningof admission
• Febrile– Paracetamol
• Poor oral intake• Decreased activity• Weak looking• Vomiting episodes• Consult TMC ER
ADMITTED
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Past Medical History
• No asthma, allergies• No previous surgeries nor hospitalizations
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Family History
• Hypertension• DM
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Birth History
• Full term via NSD to a 42 year old G1P1 (1001)
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Immunizations
• Complete for age• With booster doses
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Feeding History
• Eats a regular diet• No food allergies
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Review of Systems• General: No weight loss, poor appetite• Skin: Flushed, no rashes• Head: No migraines, dizziness and head injuries• Eyes: No blurring of vision• Ears: Good hearing, no tinnitus, earaches, infection, vertigo, no
discharges• Nose: No nasal stuffiness, discharge, and itching, nosebleeds,
and sinus trouble• Throat (Mouth/Pharynx): No sore tongue, dry mouth, sore
throat, hoarseness, and ache in the teeth and gums• Neck: No lumps, swollen glands, goiter, pain/stiffness of neck
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Review of Systems• Cardiovascular: No palpitations, orthopnea, easy
fatigability• Respiratory: No cough, sputum, hemoptysis• Gastrointestinal: No diarrhea, constipation, nausea,
(+) vomiting, no abdominal pain• Genital: No genital infections, lesions.• Renal: No polyuria, dysuria, normal urine color• Neurologic: No fainting spells, seizures, paralysis,
numbness, and tremors• Psychiatric: No anxiety, tension, depression, and
memory change. He has never had suicidal attempts.
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Physical Examination (ER)
• General Survey: Awake, ambulatory, not in cardiorespiratory distress
• Vital Signs: BP 90/60 HR 120 RR 25 T 38.6Height: 93 cm Weight: 15.2 kg
BMI 17.6 IBW 12 kg Pain scale 0/10
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Physical Examination
• Skin: Flushed, good turgor
• HEENT: Normocephalic, pink palpebral conjunctiva, anicteric sclerae, nasal septum midline, hyperemic posterior pharyngeal wall
• Neck: Supple neck, Non palpable cervical lymph nodes, thyroid not enlarged
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Physical Examination• Respiratory: Symmetrical chest expansion, no
retractions, clear breath sounds
• Cardiac: Adynamic precordium, normal rate, regular rhythm, no murmur
• Abdomen: Normoactive bowel sounds, Soft, non tender, no hepatomegaly
• Extremities: No cyanosis, swelling, full and equal pulses
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Neurologic Examination
• Mental Status: GCS 15, conversant, active, irritable• Cranial Nerves: • Cranial nerves:
I – not assessedII – pupils 2-3mm ERTLIII, IV, VI – extraocular muscles intactV – intact corneal reflex V1, V2, V3 intactVII – no facial asymmetryVIII – intact gross hearingIX, X – good gag reflexXI – can shrug shouldersXII – tongue midline
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Neurologic Examination
• Motor: 5/5• Cerebellar: No dysmmetria, dysdiadokinesia• Sensory: No sensory deficit• Reflex: +2 on all extremities• No babinski, meningeal signs
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SYSTEMIC VIRAL ILLNESS
INITIAL IMPRESSION
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Admitting Orders
Diagnostics• CBC• Urinalysis
Therapeutics• IVF: D5NM at Maintainance
+ 10 or 3.8 ml/kg• Paracetamol at 13 mkdose
q4 for T≥37.8
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LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
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1st hospital stay
Day 2 of illness
No complaints
Poor oral intake
Urine output 1 ml/kg in 8 hours
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/60 HR 126 RR 26 T 39.2-40.7FlushedSlightly hypermeic tonsilsClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses, warm extremities, CRT >2sec
SVI r/o Dengue fever
Repeat CBCDengue Ns1Dengue blotDengue PCRBCS
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LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
5/17 119 35 4.5 59 34 7 185
Dengue Ns1: positiveDengue blot: negativeDengue PCR: Type 1
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1st hospital stay
Day 1 of Illness
No complaints
Poor oral intake
Urine output 1.4ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/60 HR 126 RR 26 T 38-40.7FlushedSlightly hypermeic tonsilsClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses, warm extremities, CRT>2sec
Dengue fever
IVF increased 3.8 ml/kgDaily cbc monitoring
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2nd hospital stay
Day 2 of Illness
Loose stools + particles x 1
Urine output 2 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 90/60 HR 112 RR 24 T 38.4-39.6FlushedPuffy eyelids, bilateralDry lipsClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses, warm extremities, CRT >2sec
Dengue fever
Decreased IVF to 3 ml/kgDaily cbc monitoring
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LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
5/17 119 35 4.5 59 34 7 185
5/18 119 36 3.1 47 46 6 1 125
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3rd hospital stay
Day 3 of Illness
Loose stools x 2
Still with puffy eyes
Urine output 1.3 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 90/60 HR 118 RR 26 T 38.1-40.2FlushedDecreased eye puffinessClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses, warm extremities, CRT >2sec
Dengue fever
Decreased IVF to 2.7ml/kgProbioticsDaily cbc monitoring
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LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
5/17 119 35 4.5 59 34 7 185
5/18 119 36 3.1 47 46 6 1 125
5/19 127 38 2.3 34 59 7 115 RL
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4th hospital stay
Day 4 of IllnessOccasional
coughAbdominal
painNo recurrence
of loos stools
Urine ouput 1.7 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/60 HR 110 RR 28 T 37.5-39.1FlushedMaculopapular rashes on faceOral soresClear breath soundsRegular rhythmSoft abdomen, nontenderFull pulses
Dengue fever
Fluid is maintainedDaily cbc monitoring
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LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
5/17 119 35 4.5 59 34 7 185
5/18 119 36 3.1 47 46 6 1 125
5/19 127 38 2.3 34 59 7 115 RL
5/20 127 38 1.9 22 73 5 92 RL
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5th hospital stay
Day 5 of Illness
Persistence of abdominal pain
Urine ouput 2.9 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/60 HR 110 RR 28 T 37.3-38.7FlushedMaculopapular rashes on facePuffy eyesOral soresClear breath soundsRegular rhythmAbdominal distentionFull pulsesNonpitting bipedal edema
Dengue fever with warning signs
Cardiac, liver enzymesKidney functionBleeding parametersElectrolytesAlbuminGastro referralCardiac referral
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LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
5/17 119 35 4.5 59 34 7 185
5/18 119 36 3.1 47 46 6 1 125
5/19 127 38 2.3 34 59 7 115 RL
5/20 127 38 1.9 22 73 5 92 RL
5/21 123 36 2.7 24 70 6 72 RL
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Laboratories
CK total CK MB CKMM
5/21 662 84 578
Na K Ical
5/21 142 3.8 1.22
SGPT SGOT Alb BUN Crea
5/21 61 192 2.9 4.48 0.37
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Gastro
• A> Dengue Hepatitis
5/21 Control Patient % Act INR
PT 12.4 11.4 1 0.95
PTT 29.6 48.7
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Cardio
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Cardio
• 2d echo– Small pericardial
effusion, pleural effusion, normal intracardiac structure
• A> Dengue Myocarditis
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5th hospital stay (2 hrs prior to transfer)
DOB
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 90/60 HR 120 RR 41 T 36
Decreased breath sounds on right base
Dengue fever with warning signsDengue HepatitisDengue Myocarditis
Transfer to PICUHGT 91Chest xray
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AT PICU
Day 5 of IllnessNo abdominal
painNo recurrence
of loose stools
Urine output 2.7 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 105/52 HR 112 RR 69 T 36.9Flusheddecreased breath sounds right baseRegular rhythmSoft, nontender abdomen, no hepatomegalyFull pulses, CRT < 2 sec, warm extremities
Dengue fever with warning signsDengue HepatitisDengue Myocarditis
Serial cbc monitoring
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LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/16 124 37 8 1 84 9 6 223
5/17 119 35 4.5 59 34 7 185
5/18 119 36 3.1 47 46 6 1 125
5/19 127 38 2.3 34 59 7 115 RL
5/20 127 38 1.9 22 73 5 92 RL
5/21 123 36 2.7 24 70 6 72 RL
5/21 6pm
120 36 3.3 17 75 8 60 RL
5/21 11:30pm
106 31 3.8 24 69 7 52 RL
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WBC vs Platelet
1 2 3 4 5 6 70
50
100
150
200
250
0
1
2
3
4
5
6
7
8
9
WBCPlatelet
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Chest Xray
• Pleural effusion right
• Intercurrent Pneumonia not ruled out
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AT PICU
No complaints
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
Albumin 2.0Hct 31 from 36 (14% decreased)
Dengue fever with warning signsDengue HepatitisDengue Myocarditis
pRBC transfusion (5ml/kg)Albumin infusion (1g/kg)
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1st PICU stay
Day 6 of IllnessGoing Day 1
afebrileMinimal
abdominal pain
Better well being
Urine output 2.7 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 118/70 HR 125 RR 34 T 37.3Flusheddecreased breath sounds right baseShallow subcostal retractionsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities
Dengue fever with warning signsDengue HepatitisDengue Myocarditis
Serial cbc monitoring q6ElectrolytesAlbuminChest xrayFurosemide 0.4mg/kg/dose given 2 doses
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LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/21 123 36 2.7 24 70 6 72 RL
5/21 120 36 3.3 17 75 8 60 RL
5/21 106 31 3.8 24 69 7 52 RL
5/22 6am
121 36 2.9 30 61 8 1 50
5/22 12pm
123 37 2.9 33 62 5 56 RL
5/22 6pm
117 35 3.2 30 63 6 1 56 RL
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Laboratories
Na K Ical
5/21 142 3.8 1.22
5/22 140 3.8 1.13
SGPT SGOT Alb BUN Crea
5/21 61 192 2.9 4.48 0.37
5/22 3.3
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Chest Xray
• Regressing pleural effusion right
• Intercurrent Pneumonia cannot be totally ruled out
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2nd PICU stay
• Day 7 of Illness
• Going Day 2 afebrile
• No complaints
• Better well being
• Urine output 2 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 107/60 HR 88 RR 24 T afebrileFlushedHarsh breath soundsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities
Dengue hemorrhagic feverDengue HepatitisDengue Myocarditis
Serial cbc monitoring q12ElectrolytesAlbuminCardiac enzymesPTCreatinine
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LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/21 123 36 2.7 24 70 6 72 RL
5/21 120 36 3.3 17 75 8 60 RL
5/21 106 31 3.8 24 69 7 52 RL
5/22 121 36 2.9 30 61 8 1 50
5/22 123 37 2.9 33 62 5 56 RL
5/22 117 35 3.2 30 63 6 1 56 RL
5/236am
118 35 3.3 28 67 2 3 88
5/23 6pm
112 33 3.3 18 72 7 3 116 RL
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LaboratoriesNa K Ical
5/21 142 3.8 1.22
5/22 140 3.8 1.13
5/23 138 4.1 1.1
SGPT SGOT Alb BUN Crea
5/21 61 192 2.9 4.48 0.37
5/22 3.3
5/23 3.4 0.42
CK total CK MB CKMM
5/21 662 84 578
5/23 268 76 192
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3rd PICU stay
Day 8 of illnessGoing Day 3
afebrileBetter well
beingImproving
appetiteUrine output
1.3 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/70 HR 88 RR 22 T 36.7PinkClear breath soundsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities
Dengue hemorrhagic feverDengue HepatitisDengue Myocarditis
Transfer to regular room
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8th hospital stay
Day 8 of illness
Going Day 3 afebrile
Noisy breathing
DysuriaUrine output
1 ml/kg
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/70 HR 88 RR 22 T 36.7PinkClear breath soundsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities
Dengue hemorrhagic feverDengue HepatitisDengue Myocarditis
UrinalysisSalinase
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5/25Color Dark yellow RBC 2
Transpency Slightly cloudy WBC 7
pH 7.0 Epithelial cells 15
Specific gravity 1.010 Casts 0
Blood + Bacteria 24
Protein +
Glucose -
Leucocytes +
Ketones +
Urobilinogen +
Bilirubin +
Nitrites -
Laboratories
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9th hospital stay
Day 9 of illness
Going Day 4 afebrile
PLANSUBJECTIVE OBJECTIVE ASSESSMENT
BP 100/60 HR 90 RR 24 T 36.9PinkClear breath soundsRegular rhythmSoft, nontender abdomenFull pulses, CRT < 2 sec, warm extremities
Dengue hemorrhagic feverDengue HepatitisDengue MyocarditisUTI
May go home
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LaboratoriesHg Hc WBC Band Neu Lym Mon
oEo Plt
5/21 123 36 2.7 24 70 6 72 RL
5/21 120 36 3.3 17 75 8 60 RL
5/21 106 31 3.8 24 69 7 52 RL
5/22 121 36 2.9 30 61 8 1 50
5/22 123 37 2.9 33 62 5 56 RL
5/22 117 35 3.2 30 63 6 1 56 RL
5/23 118 35 3.3 28 67 2 3 88
5/23 112 33 3.3 18 72 7 3 116 RL
5/26 136 41 5.8 24 66 8 2 164 RL
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Laboratories
SGPT SGOT Alb BUN Crea
5/21 61 192 2.9 4.48 0.37
5/22 3.3
5/23 3.4 0.42
5/26 91
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Discharge
• Discharged on the 8th Hospital stay• Home medications– Cefuroxime (dose) for UTI
• Follow up prior to going back to Malaysia
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DENGUE HEMORRHAGIC FEVERDENGUE HEPATITISDENGUE MYOCARDITIS
Final Diagnosis