Asuncion * Dalman * Doromal * Dy Generoso * Mejia * Ong Internal Medicine Rotation- The Medical City December 22, 2010 1 G7 Grand Rounds
Jan 04, 2016
Asuncion * Dalman * Doromal * DyGeneroso * Mejia * Ong
Internal Medicine Rotation- The Medical CityDecember 22, 2010
1
G7 Grand Rounds
Identifying Data
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• CFG, 58 y/o • Filipino female• Roman Catholic• From Pasig• Informants: Patient and sister (good
reliability)
Chief Complaint
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• Epigastric pain
History of Present Illness
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• Post-prandial epigastric pain (6/10) crampy, intermittent, 30 minute duration, with radiation to the back
• Took Itopride (Ganaton) no relief• (-) fever, nausea, vomiting, changes in bowel
movement
Morning PTA
Afternoon PTA• Epigastric pain with increased intensity; (+) chills and
fever• Consult at TMC-ER admission
Review of Systems
• (+) generalized weakness• No weight gain or weight loss, easy fatigability• No headache, seizures, blurring of vision, ear
problems• No dyspnea, cough, colds• No Palpitations, chest pain• No nausea, vomiting• No dysuria, frequency
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Past Medical History
• (+) Hypertension – 20 years• S/p laparoscopic cholecystectomy with
subsequent development of stricture, s/p stent placement (2005)
• S/p biliary stent replacement (2007)• Allergic to erythromycin – rashes
Past Medical History
• Hypertension– 20 years– On Losartan + Hydrochlorohiazide
• Asthma– No recent consults– Last attack unrecalled– No maintenance medications
Family History
• Hypertension• Asthma
Personal and Social History
• Divorced• Smoker• Occasional alcohol beverage drinker• Usual diet: prefers meat and fatty food, soda
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Physical Exam
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• Anthropometrics: Height=152 cm, weight=68 kg, BMI=29.4 (overweight)• Vitals: BP: 150/90, T: 39.5oC, RR 21, HR 88• General: conscious, coherent, alert• HEENT: anicteric sclerae, pink palpebral conjunctiva,
neck veins non-distended, no cervicolymphadenopathies• Chest: Symmetric chest expansion, no retractions ,
clear breath sounds
Physical Exam
Abdomen: Protuberant, normoactive, tympanitic, no masses palpated, scar on the left upper quadrant, epigastric and right upper quadrant direct tenderness
Extremities: Full and equal pulses, good skin color and turgor
Digital rectal exam:
Salient Features
• 58 year old, female• Acute abdominal pain (epigastric, RUQ areas)• Accompanied by chills and fever• History of cholecystectomy with biliary stent
insertion and replacement (2005 and 2007)
ASSESSMENTAscending cholangitis
Differential Diagnosis
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• Cholecystitis and biliary colic
• Diverticular disease• Hepatitis• Mesenteric ischemia• Pancreatitis
• Cirrhosis• Liver failure• Liver abscess• Acute appendicitis• Perforated peptic ulcer• Pyelonephritis
Hepatitis
Pancreatitis
Peptic Ulcer Disease
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Diagnostic Plan (1 of 2)
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Diagnostic Plan (2 of 2)
COURSE IN THE WARDS
Hospital Day 1: Floors to ICUSubjective Objective Assessment Plan
• Stable at the floors early in the AM • Decreased responsiveness• Restlessness
BP: 160/60 90/60HR: 100sRR: 40sO2 sat’n: 97% 88%+ alar flaring+ ronchi, ralesOccasional wheezingDistended abdomen; soft, non-tenderNormal rate, regular rhythmDistinct S1No edemaFull and equal pulsesFlushed skin
Severe septic shock secondary to ascending cholangitis secondary to biliary duct stricture s/p stent placement
Hypertension
• Intubation• Transfer to ICU• Stat ERCP• Antibiotics (Pip-Tazo Linezolid and Imipenem)
Hospital Day 1 – DiagnosticsCBC
Hemoglobin = 132 g/dLHematocrit = 0.37Platelets = 224WBC = 14.5Neutrophils = 0.93Lymphocytes = 0.06Monocyte = 0.01
Urinalysis
Color: Dark yellowSp Gravity: 1.015+ erythrocytes, urobilinogen, bilirubin
ABGpH = 7.382pCO2 = 26.4pO2 = 63.1HCO3 = 15.7BE = -7.1O2 sat = 91.73
Liver Function TestsHepatitis tests: non-reactiveSGOT: 542.7 U/L ↑SGPT: 636.8 U/L ↑Alk Phos: 137.1 U/L ↑Total Bilirubin: 6.17 mg/dL ↑Direct Bilirubin: 4.02 mg/dL ↑Indirect Bilirubin: 2.15 mg/dL ↑
Hospital Day 1 – DiagnosticsECG
Normal sinus rhythmLeftward axisLeft atrial enlargementNon-specific ST-T wave changesNo significant changes from 11/27/2010
Chest X-ray
Subsegmental atelectasis, rightCardiomegalyAtheromatous aortaThoracic spondylosis and dextroscoliosis
Cardiac Enzymes
Troponin-T = 0.57 ng/mL*CK Total = 306.3 U/L ↑CK MB = 23.44 U/LCK MM = 282.9 U/L ↑
Cultures
Stent and blood: Klebsiella pneumoniaeBile: Heavy growth of Escherichia coliStent: Proteus mirabilis•All orgnisms sensitive to Ceftriaxone
Hospital Day 1 – DiagnosticsSerum Electrolytes
Sodium: 139 meq/LPotassium: 3.3 meq/L
OthersAmylase: 126 U/L ↑Lipase: 96.56 U/L ↑Lactate: 50.52 mg/dL ↑Creatinine: 0.64 mg/dLNGAL: 225.2 ng/mL ↑
At the end of the 1st hospital day...
• CNS: GCS 11, sedation with Midazolam• CVS:– BP: 75/40 to 150/70, tachycardic hypotensive
episodes– On dopamine and/or norepinephrine drip– (+) Trop T, elevated CK enzymes, anterior wall
ischemia on ECG– Given Enoxaparine (Clexane), 0.6 ml every 12
hours
At the end of the 1st hospital day...
• Respiratory:– Oxygen saturation = 98%– (+) ronchi bilaterally– (+) rales on the right base
• IDS– Febrile– On linezolid and imipenem
• Unremarkable gastrointestinal, genitourinary and endocrine findings
Assessment at the end of the 1st hospital day...
• Acute respiratory failure secondary to septic shock secondary to ascending cholangitis
• Asthma vs. COPD in acute exacerbation• Hypertension, to consider non-ST elevation
myocardial infarction
Plan at the end of the 1st hospital day...
• Close monitoring
• Maintain hemodynamic stability
• Administration of antibiotics
• Mechanical ventilation
Hospital Day 4: in the ICUSubjective / Objective Assessment Plan
• CNS: GCS 11 (E4VtM6) with episodes of agitation; on Midazolam 5 ml/hr• CVS: BP: 135/60, HR: 91, off norepinephrine• Respiratory: no desturations, clear breath sounds; on mechanical ventilation with 60% FiO2• GI: NGT feeding; melena episode• GU: adequate input and output; (+) hematuria; Crea=0.67; Na=150; K=3.4• IDS: afebrile, on Imipenem Day 3• Endo: CBG – 128 mg/dL
Septic shock secondary to ascending cholangitis s/p ERCP
Hypertension t/c non-ST elevation MI
Acute kidney injury
Anemia probably secondary to upper GI bleed
• Close monitoring • For blood transfusion• Ulcer prophylaxis• Potassium correction• For step-down antibiotics – Ceftriaxone and Ampicillin (culture-guided)• Possible mechanical ventilation weaning (extubation on hospital day 6)
CBCHemoglobin = 83 g/dL
Hematocrit = 0.25Platelets = 119
WBC = 15.4Bands = 0.02
Neutrophils = 0.85Lymphocytes = 0.08
Monocyte = 0.04Eosinophil = 0.01
Hypochromic
Course in the Hospital
• Day 6 – extubated; well-tolerated
• Day 7 – transfer to the floors
• Day 12 – discharged
Principles of Management
Septic Shock Ascending Cholangitis
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• Close monitoring (vital signs, I/O)
• Hemodynamic support with IV fluids and vasopressors
• Identify underlying cause for sepsis
• ABC assessment• IV Fluid resuscitation with
crystalloids (e.g. plain NSS)• Parenteral antibiotics• Biliary decompression
(severe cases)• Extracorporeal shockwave
lithotripsy (ESWL) for choleliths
Source: http://emedicine.medscape.com/article/774245-media
Looking Ahead – Ascending Cholangitis
Prognosis Complications• Depends on the following:
– Early recognition and treatment of cholangitis
– Response to therapy– Underlying medical conditions
of the patient• Mortality rate: 5-10%, (higher
in patients who require emergency decompression or surgery)
• Good response to antibiotics = good prognosis
• Liver failure, hepatic abscess, microabscess
• Acute renal failure• Bacteremia, sepsis (gram-
negative)
Looking Ahead – Septic Shock
Prognosis Complications• Depends on the following:
– Severity of illness– Co-morbidities– Age
• Response to antibiotics
• Acute respiratory distress syndrome (ARDS)
• Renal dysfunction• Disseminated intravascular
coagulation (DIC)• Mesenteric ischemia• Myocardial ischemia and
dysfunction
Other Aspects of the Case
Psycho-socio-economic Impact Prevention and Public Health• P100,000 per day with ICU
admissions current expense for the patient is around P400,000
• On patient’s personal account
• Lifestyle and health-seeking behavior changes (e.g. low-fat diet, quit smoking, stent-removal)
• Patient education
Asuncion * Dalman * Doromal * DyGeneroso * Mejia * Ong
Internal Medicine Rotation- The Medical CityDecember 22, 2010
36
G7 Grand Rounds