CPC 1 For Printing

UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center

Aurora Boulevard, Quezon City
CLINICOPATHOLOGIC CONFERENCE
Date: July 15, 2015, CPC #1
Champions
Venue: University Auditorium 1 & 2
Time: 8:00 10:00 AM
Discussants: 42nd Interscholastic CPC
Dr. Kea T. Carpio Presentor

Dr. Jeryl T. Yu - Presentor
Dr. Melissa Therese S. Guillermo
Dr. Darell C. Wuisan
Dr. Erica Ayn V. Yarra
Pathologist: Dr. Janelyn Alexis Dy-Ledesma
Moderator: Dr. Edward M. Santos
Reactors: Dr. Victor S. Doctor, Dr. Lino
S. Pabillo
Dr. Milagros S. Bautista, Dr. Marieannebelle P.
Tablante
CASE PROTOCOL
This is the case of 16 year old female, right handed, Roman Catholic from Valenzuela who
presented at the pediatric emergency room due to difficulty of breathing.
Chief Complaint: Dyspnea of 3 weeks duration
History of Present Illness:
Nine months prior to admission, she started to have productive cough and easy
fatigability. Weight loss was also observed, roughly quantified at 50%. There was no fever,
dyspnea, or anorexia. No consults were done, or medication given.
Three months prior to admission, she started to have dyspnea at rest, and orthopnea. She
sought consult at a private clinic where she was prescribed Fixcom, 3 tablets once a day, to
which she complied. Symptoms were allegedly partially relieved.
One month prior to admission, there was a gradual increase of abdominal girth and
bipedal edema. No consult was done.
Thirteen days prior to admission, she experienced worsening of her dyspnea, with an
associated vague chest pain. She consulted at San Lazaro, where she was admitted. She was
given IV Penicillin and an unrecalled diuretic. After three days, with partial relief of dyspnea, she
went home against medical advice.
One day prior to admission, there was recurrence of dyspnea, which prompted consult at
the pediatric emergency room.
Review of systems:
(+) pallor
(-) weakness, loss of consciousness, headaches, seizures
(-) ear discharge, tinnitus
(-) hemoptysis
(-) hematemesis, abdominal pain, jaundice, diarrhea, constipation, hematochezia, melena
(-) oliguria, hematuria
(-) muscle pain
(-) rashes, easy bruisability
Past medical history:
(-) bronchial asthma, hypertension, diabetes mellitus, allergies
(+) PTB exposure neighbors
Family medical history:

(+) hypertension father
(+) diabetes mellitus mother
Birth and maternal history:
She was born full term to a then 27 year old G1P0 via spontaneous vaginal delivery at home care
of a midwife, with no fetomaternal complications.
Immunization history:
(+) BCG, OPVx3, DPTx3, Hepatitis B x3, measles
Personal/social history:
Mother is a 43 year old housewife, father is a 45 year old welder.
Patient is the eldest of 4 children.
Nutritional history:
Patient was formula fed. Prior to her illness, her diet consisted of rice and meat, with no
preferences.
Developmental history
Unremarkable.
Physical Examination
Patient was awake, coherent, in mild respiratory distress, with the following vital signs: BP
90/60, HR 120, RR 45, afebrile, with a weight of 39.5 kg.
She had anicteric sclerae, pale conjunctivae, and periorbital edema. She had alar flaring,
and suprasternal retractions. Several bilateral cervical lymphadenopathies were palpated.
She had an adynamic precordium. On auscultation she had regular cardiac rhythm, a loud
P2, and no murmurs.
She had equal chest expansion, and slight intercostal retractions. Coarse crackles were
auscultated on bilateral lung fields, but there was no wheezing.
Her abdomen was globular and nontender. The right abdominal quadrants are dull. The
Traube space was obliterated.
Her pulses were strong, with capillary refill time < 2 secs. She had bipedal pitting edema.
Course in the ER:
She was hooked to O2 support at 10 LPM, and an IV fluid line was started (D5LR).
The following were requested: CBC, electrolytes, liver enzymes, urinalysis, sputum and urine AFB
x 3 days, ABG, and a Chest Xray PAL.
ABG showed FiO2 60%, pH 7.429, pCO2 28.4, pO2 99.2, HCO3 18.8, BE -3.4, O2 saturation
of 97.6%.
Chest X-ray was done.
She was started on Penicillin G, 2 million U IV q6, and Dobutamine drip, and maintained on
O2 support. She was referred to the pulmonology and cardiology services.
2D Echo showed minimal pericardial effusion, mild pulmonary artery hypertension (32 mmHg),
and an ejection fraction of 59%.
CBC showed a haemoglobin of 65, hematocrit 0.222, RBC 2.91, MCV 76.3, MCH 22.3,
MCHC 293, RDW 20.6, Platelet 376, and WBC 8.87.
Blood chemistry showed glucose 4.46, BUN 2.92, Creatinine 53, Albumin 18, total bilirubin
3.84, direct bilirubin 0.77, indirect bilirubin 3.07, AST 68, ALT 45, Ca 1.96, Na 127, K 3.7, Cl 96.
Urinalysis showed amber colored, hazy urine with specific gravity of 1.6, pH 6.8, Albumin
+1, Glucose negative, numerous WBC, numerous RBC (70% dysmorphic), and bacteria 5-10.
Patient was transferred to the ward, with a plan for blood transfusion.
Day 1:
At the ward, she had BP 100/50, HR 130s, with clammy extremities. ABG showed pH
7.476, pCO2 32.6, pO2 57, HCO3 24, BE 2, O2 saturation 91.7%. Dobutamine dose was
increased, and she was referred to the pediatric ICU. She was started on dopamine, and her fluid
was shifted to D5NSS. Due to severe respiratory distress, she was eventually intubated. An NGT
was also inserted.
Repeat ABG showed pH 7.342, pCO2 54.8, pO2 462.2, HCO3 29.7, BE 2.9, O2saturation 99.9%.
2
Day 2:
On the second ward day, she was asleep but arousable, still with pallor. Her BP was 90/60,
HR 110s, RR 20s, and she was afebrile. Crackles were auscultated bilaterally, and her extremities
were warm. Endotracheal aspirate was sent for gram stain and culture. A repeat CBC showed
haemoglobin of 64, hematocrit 0.220, RBC 2.84, MCV 77.5, MCH 22.5, MCHC 293, RDW 20.1,
Platelet 519, and WBC 16.06. Neutrophils were 0.924, lymphocytes 0.019, monocytes 0.054,
eosinophils 0.002, basophils 0.001. Blood chemistry showed Na 137, K 4.0, Cl 104. Patient was
started on HRZE, cefuroxime, and famotidine with a plan to start sildenafil and beraprost.
Day 3:
Her temperature ranged from 37C to 39C. There was bilous output per NGT. Paracetamol
was added to the medication regimen. She was also being weaned off the mechanical ventilator.
Day 4:
On the 4th hospital day, there was an episode of desaturation (80%) while on FiO2 of 80%.
At this time, her BP was 100/60, HR 150-160, RR 30, O2 saturation of 99%.
Patient was later brought to radiology for holoabdominal ultrasound. At this time her BP was
100/60, HR 154, RR 30, temperature 39oC, and O2 saturation was 99%.
Back at the ward, patient was referred for HR=0 while endotracheal suctioning was being done.
ACLS was performed for 27 minutes. Patient was not revived.
Anicteric slcerae, pale conjunctivae, and periorbital edema. She had alar flaring, and
suprasternal retractions. Several bilateral cervical lymphadenopathies were palpated.
She had an adynamic precordium. On auscultation she had regular cardiac rhythm, a loud
P2, and no murmurs.
She had equal chest expansion, and slight intercostal retractions. Coarse crackles were
auscultated on bilateral lung fields, but there was no wheezing.
Her abdomen was globular and nontender. The right abdominal quadrants are dull. The Traube
space was obliterated.
Her pulses were strong, with capillary refill time < 2 secs. She had bipedal pitting edema.
DIAGNOSTICS
Arteria
l blood
ER at
gas
4am
Day 1,
12mn
FiO2
pH
pCO2
pO2
HCO3
BE
O2sat
60
7.476
32.6
57
24
2
91.7
60
7.429
28.4
99.2
18.8
-3.4
97.6
Day 1
100
7.342
54.8
462.2
29.7
2.9
99.9
Day 1,
8am
Day 1,
10am
Day 2,
2am
Day 4,
2am
Day 4,
8am
90
7.298
53.5
129.6
26.2
-1
98.1
80
7.34
37.6
196.8
20.2
-4.6
99.2
60
7.45
42.8
96.5
29.7
5.8
97.5
100
7.318
58.4
79
29.9
2.5
94.5
100
7.483
41
204.9
30.7
7.5
99.5
Holoabdominal Ultrasound:
Minimal ascites.
Pyonephrosis, right, cannot rule out pyelonephritis with abscess formation.
Normal liver, spleen, pancreas, left kidney.
AFB smears:
Endotracheal aspirate: Day1 and Day2 - negative.
Urine: Day1, Day2, Day 3 negative.

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UNIVERSITY OF THE EAST

Ramon Magsaysay Memorial Medical Center

Discussants: 42nd Interscholastic CPC

Dr. Kea T. Carpio Presentor

Family medical history:

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