sample of mortality & Morbidity 2011

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sample of mortality & Morbidity 2011

  1. 1. Perpetual Succour HospitalDepartment of Family & Community MedicineMORBIDITY & MORTALITY CONFERENCE FEBRUARY 2010 Presentors: Liza D. Mariposque, M.D. Philip March Alquizar, M.D. Marie Micheau Conference Room February, 2011
  2. 2. TOTAL HOSPITAL ADMISSIONS 1,213 Internal Medicine 577 (47.57%) Pediatrics 215 (17.72%) Family Medicine 148 (12.20%) Obstetrics and Gynecology 138 (11.38%) Surgery 135 (11.13%)
  3. 3. FAMILY MEDICINEAdmissions : 148OPD: PSH : 273 Community : 14House Case : 9Co-managed : 44Charity : 2Mortality : 2
  4. 4. Family Medicine Cases AdultMedicine 78 (68.42%) Pediatrics 24 (21.05%) Surgery 9 (7.90%) OB & GYN 3 (2.63%)
  5. 5. FAMED LEADING CAUSES OF MORBIDITIESADULT: Community Acquired Pneumonia Urinary Tract Infection Acute Gastroenteritis
  6. 6. ADULT MEDICINE 78(68.42%) HEENT 9Upper Respiratory Tract Infection 1Sinusitis 4 Maxillary, Bilateral w/ Acute Bronchitis ………..….1 w/ DM 2 ……………1Acute Tonsillitis 4 w/ Dyslipidemia ……………1 w/ HPN ……………1
  7. 7.  CARDIOVASCULAR SYSTEM 12Hypertensive Urgency 4 © w/ CAP-MR; …………………………1 Lichen Simplex Chronicus (toes); Cholelithiasis; Uterine Myoma; Chronic Venous Insufficiency; HCVD w/ Dyslipidemia, UTI …………………..1
  8. 8. Hypertension Stage II 3 w/ Error of Refraction ……………1 w/ Hypertensive Nephrosclerosis, w/ Maxillary Sinusitis ..……1 w/ DM2 ………………………….1Dilated Cardiomyopathy 1 2ndary to HCVD, DM2, w/ Viral Epidemic Keratoconjunctivitis
  9. 9. Chronic Stable Angina 1 w/ CAD, DM2, Colonic Polyp ………1 S/P Colonoscopy 2/11Congestive Heart Failure 2 FC-II,HCVD, DM2 …………………1 FC-III, CD-AF w/ MVR; CAP-MR, HCVD,CAD, DM2, DVI…………..1
  10. 10. Ŧ Probable Aortic Dissection, 1 Proximal Aorta, HCVD, DM 2
  11. 11. INTERNAL MEDICINE RESPIRATORY SYSTEM 12Acute Bronchitis 2Pulmonary Tuberculosis 1 Class III w/ DM Type 2Chronic Obstructive Pulmonary Disease 1 in Acute Exacerbation w/ Ulcer-like-Dyspepsia
  12. 12. Community Acquired Pneumonia 8 Low Risk 2 w/ Asthmatic Component ……1
  13. 13. CAP - Moderate Risk 6 w/ DM 2, Uncontrolled ……………….….1 w/ HCVD, DM2, Dyslipidemia ……………….1 w/ CKD 2ndary to HPN Nephrosclerosis, HCVD …………………………………..….1 w/ Maxillary & Ethmoidal Sinusitis ………1 w/ Lumbosacral Radiculopathy probably 2ndary to TB/Malignancy; Internal Hemorrhoids; Cholelithiasis ……………..1
  14. 14. INTERNAL MEDICINEGASTROINTESTINAL SYSTEM 5Cholelithiasis 1Chronic Liver Disease 1 2ndary to Schistosomiasis, w/ Hypersplenism 2ndary to Schistosomiasis …………………1Decompensated Liver Cirrhosis© 1 2ndary to Chronic Hepatitis B Infection
  15. 15. Upper GI Bleeding 1 2ndary to Erosive Gastritis w/ CKD 2ndary to HPN Nephrosclerosis; HCVD; CD-AF w/ MVR …………………….1
  16. 16. Adenocarcinoma, Rectosigmoid© 1 Anemia 2ndary to # 1 S/P Colonoscopy 2/21
  17. 17. INTERNAL MEDICINE GENITO-URINARY SYSTEM 10Urinary Tract Infection 7 w/ Non-Ulcer Dyspepsia ……..1 w/ Rhinosinusitis …………………...1 w/ Essenntial HPN …………………...1 w/ HPN & Dyslipidemia …………….1Acute Pyelonephritis 1Ureterolithiasis, L 2
  18. 18. MUSCULOSKELETAL SYSTEM 1MUSCULOSKELETAL SPASM 1
  19. 19.  SKIN 1Cellulitis, R foot 1 w/ UTI
  20. 20. RHEUMATOLOGY 2Acute Gouty Arthritis 2 S/P Arthrocentesis ………………………1 CKD 2ndary to Urate Nephrolithiasis, w/ Indirect Hernia, L ………………..1
  21. 21. ONCOLOGY 2Breast Carcinoma 1 Stage II-B, S/P Chemotherapy 8th Cycle S/P Lumpectomy, RBronchogenic Carcinoma 1 w/ DM 2
  22. 22. INTERNAL MEDICINE NERVOUS SYSTEM 5Benign Paroxysmal Positional Vertigo 2 w/ Non-Ulcer like Dyspepsia, Nephrolithiasis© …………………….1 w/ Acute Gastritis …………………….1Seizure Disorder 1 w/ Maxillary Sinusitis, HPN
  23. 23.  CARDIOVARCULAR DISEASE 2Multiple Infarct, L MCA w/ Seizure Disorder 2ndary to #1 HCVD, Hypercholesterolemia…….1Pontine Infarct w/ HCVD, CAD…………..1
  24. 24. INTERNAL MEDICINE ENDOCRINE SYSTEM 1Hypoglycemia 1 2ndary to Poor Food Intake, DM 2 w/ CAP- Moderate Risk
  25. 25. INTERNAL MEDICINEINFECTIOUS 18Systemic Viral Infection 2Dengue Fever 4 Stage IITyphoid Fever 2 w/ HPN …………………1
  26. 26. Acute Gastroenteritis 5 w/ some Dehydration 4 w/ Maxillary Sinusitis …………..1 w/ Moderate Dehydration 1Intestinal Amoebiasis 2 w/ Mixed Hemorrhoids ……………1
  27. 27. Hepatitis A Infection 1 w/ CholelithiasisŦ Septic Shock Syndrome 1 2ndary to CAP - High Risk w/ Concomittant Non-ST Elevation Myocardial Infarction
  28. 28. Human Immunodeficiency Virus Positive 1 w/ Multiple Intracranial Enhancing Lesion (Toxoplasmosis), UGIB probably 2ndary to Stress Ulcers Gastropathy – Resolved. w/ Herpes Zoster, R Thigh - Resolved
  29. 29. Mortality # 1 T.D, 78 y.o., female, widow Mabolo, Cebu City CC: dyspnea, upper back pain Past Medical History: HPN, DM2 Numbers of Hospital Stays: 5 days
  30. 30. Final Diagnosis PROBABLE AORTIC DISSECTION, PROXIMAL AORTA HYPERTENSIVE CARDIOVASCULAR DISEASE DIABETES MELLITUS 2
  31. 31. Mortality # 2 N.C.,50 y.o., male CC: epigastric pain, dyspnea Past medical History: HPN Numbers of Hospital Stay: 4 Hours
  32. 32. Final Diagnosis Septic Schock Syndrome 2ndary to CAP High Risk with Concomittant Non-ST Elevation Myocardial Infarction
  33. 33. MORBID CASE V.V.,21y.o., male Medical Representative Talamban, Cebu City CC: fever, headache, changes in behavior
  34. 34.  (-)HPN, (-) DM, (-) BA VICES: alcoholic beverage drinker, smoker Allergy: shrimp HFD: BA
  35. 35. PAST MEDICAL HISTORY2009 – AGE (PSH)April 2010 – Pneumonia (PSH)June – Nov. 2010 – PTB (CVGH)Oct. 2010 – Optic Pneuritis & Glaucoma 2ndary to adverse drug reaction to Ethambutol.
  36. 36. HPI2 wks PTA – undocumented on & off fever. No History of cough.5 Days PTA – still with fever associated with body malaise & headache.Day PTA – changes of behavior.
  37. 37. BP: 130/90mmHg HR: 86bpmRR: 20cpm T: 36.1CSkin: no lesions, warmHEENT: anecteric, dilated R pupil (5mm) & non- reactive to light. (+) L eye reactive to LightNeck:(-) LAD, no neck rigidityC/L: ECE, CBS, (-)rales, (-)wheezeCVS: DHS, NRRR, no murmurAbd.: flat, NABS, nontender, no massGUT: (-)KPSExt. : No edema, strong pulses, no limitation in movement
  38. 38. CNS: drowsy, incoherent, follows commandI – N/AII, III, - dilated R pupil & non-reactive to light, L pupil is reactive to light.III, IV,VI – (+)EOMV, VII – No facial asymmetryIX, X, XI – (+) gag reflex, tongue at medline, able to swallow & protrude tongueXI – no shoulder lag
  39. 39. Sensory: IntactMotor Strength: 5/5 all extremitiesReflexes: RU = +2 LU = +2 RL = +2 LL = +2(-) Babinski sign(-) Kernigs sign(-) Brudzinsky sign
  40. 40. Admitting Impression: R/I Bacterial Meningitis vs. Space occupying Lesion
  41. 41. On Admission: Hypoallergenic Diet O2 inhalation at 2Lpm. IVF started @ 30gtt/min. Labs: CBC, U/A, Na, K, CXR, crea, CT-scan brain plain Meds: Vit. B – complex 1 tab OD. Mefenamic acid 500mg 1cap now. Ceterizine 10mg 1tab OD Ceftriaxone 2G IVTT q 12Hr.
  42. 42. Laboratory Results: CBC  U/AWBC = 4.97 Glucose (-)N = 63 Protein (-)L = 20 pH 1.010M=7 RBC = 0-2E = 10 WBC = 0-2Plt = 189 Epithelial = rareHb = 12.3 Mucus = rareHct = 35.7 Bacteria = rare
  43. 43.  CXRNo Significant Findings  Na = 133  K = 3.77  Crea = 0.96
  44. 44. CT-SCAN BRAIN PLAIN Areas of ill-defined hypodensities with mass effect in the R basal ganglia, R frontal & R temporal lobes, R thalamus & R midbrain. Consideration include:1. Cerebritis2. Vasogenic Edema3. Infection from Vasculitis
  45. 45.  Course in the Ward: Day 1-3 P: fever, headache, rashes O: BP: 120/80-140/90 HR: 80-110bpm RR: 20-24cpm T: 37.5-39CSkin: (+) maculopopular rash, warmHEENT: anecteric, dilated R pupil (5mm) & non- reactive to light. (+) L eye reactive to LightNeck:(-) LAD, no neck rigidityC/L: ECE, CBS, (-)rales, (-)wheezeCVS: DHS, tachycardic, no murmurAbd.: flat, NABS, nontender, no massExt. : No edema, strong pulses, no limitation in movement
  46. 46. A: CNS INFECTION, R/I HIV INFECTIONP:For MRI of the brain w/ contrast.> Rpt CBC For HIV Test & VDRL. For co-mgt w/ Neurologist. Refer to Allergology for clearance. Co-mgt w/ Infectious Specialist. Keppra 500mg 1tab BID. Mannitol 100cc IV q 6H. Iterax 50mg 1tab OD. d/c Ceftriaxone.
  47. 47. MRI OF THE BRAIN w/ Contrast Mulltipleminimally enhancing cerebellar and brain stem lesion w/ perilesional edema and mass effect. Primary consideration is an infectious CNS process such as Toxoplasmosis.
  48. 48. HIV Test VDRL Test  Qualitative Result – Negative HIV Ag/Ab 457.71 s/co  CBCRemarks: Positive WBC = 3.72 N = 54 L = 26 M=8 E = 12 Plt = 165 Hb = 12.1 Hct = 32.5
  49. 49.  Day 4-5 P: fever, no verbal output but patient response upon calling his name, (+) rashes, unable to eat O: BP: 110/70-140/90 HR: 80-150bpm RR: 20-25cpm T: 39-41C
  50. 50. Skin: (+) maculopopular rash, warmHEENT: anecteric, dilated R pupil (5mm) & non- reactive to light and half open.Neck:(-) LAD, no neck rigidityC/L: ECE, CBS, (-)rales, (-)wheezeCVS: DHS, tachycardic, no murmurAbd.: flat, NABS, soft, nontender, no massExt. : No edema, strong pulses, no limitation in movement
  51. 51. A: HIV Infection, R/I CNS Infection (Toxoplasmosis vs. Lymphoma) UGIB etiology to be determineP: NPO & NGT inserted. - for HbsAg and anti-HCV determination. - Piperacillin-Tazobactam 4.5G IV then 2.5G IV q 6H. - Nexium 40mg IVTT OD. - Fansidar 25/500mg 4tabs now then 1tab q 8H once coffee ground vomitus disappeared. - all P.O meds shifted to IV.
  52. 52. HbsAg = 1 (NR)Anti-HCV = 1 (NR)2 blood culture: negative
  53. 53.  Day 6-8 P: fever, no verbal output but response upon calling his name, recurrence of coffee ground NGT drainage, (+) vesicular rash O: BP: 110/70-130/90 HR: 85-140bpm RR: 20-22cpm T: 38-40C
  54. 54. Skin: warmHEENT: anecteric, dilated R pupil (5mm) & non- reactive to light and half open.Neck:(-) LAD, no neck rigidityC/L: ECE, CBS, (-)rales, (-)wheezeCVS: DHS, tachycardic, no murmurAbd.: flat, NABS, soft, nontender, no massExt. : No edema, (+) vesicular rash on the R thigh, strong pulses, w/ limitation in movement on the L side of the body.
  55. 55. A: HIV Infection, R/I CNS Infection (Toxoplasmosis vs. Lymphoma) UGIB etiology to be determine, Herpes Zoster R ThighP: NGT feeding started. - for CD4 count and Toxoplasma Serologic IgG & IgM determination. - hold fansidar. - Zithromax 500mg IV drip OD. - Dalacin 300mg 1tab/NGT q 6H  hold - Valtrex 1G 1tab q 8H/NGT  hold
  56. 56.  Dexamethasone 50mg IVTT q 6H. Zovirax 500mg IV infusion. Kabiven 1.4Kcal to run q 24H. Ice bath done. Refer to Neurosurgeon for possible brain biopsy.
  57. 57.  Day 9 - 12 P: fever, no verbal output but response upon calling his name, (+) vesicular rash, (+) Chyne- Stokes respiration O: BP: 110/70-140/80 HR: 85-160bpm RR: 20-23cpm T: 37.5-40.8C
  58. 58. Skin:warmHEENT: anecteric, dilated R pupil (5mm) & non- reactive to light and half open.Neck:(-) LAD, no neck rigidityC/L: ECE, CBS, (+)rales both Lung field, (-)wheezeCVS: DHS, tachycardic, no murmurAbd.: flat, NABS, soft, nontender, no massExt. : No edema, (+) vesicular rash on the R thigh, strong pulses, w/ posturing/extension of L upper extremities.
  59. 59. A: HIV Infection, R/I CNS Infection (Toxoplasmosis vs. Lymphoma) UGIB probably 2ndary to Stress Ulcer, Herpes Zoster R ThighP: - Rpt CXR done. - Resume Valtrex. - Paracetamol given RTC. - Mucosta 100mg 1tab BID. - Hold Pepiracillin. - Cefipime 2G IVTT q 12H. -
  60. 60.  Acetylcytine 600mg mix in water BID. Salbutamol nebulization q 6H. Inc. Keppra 100mg 1tab BID. Inc. Mannitol 100cc q 6H. Family appraised for brain biopsy.
  61. 61.  Day 13 - 21 P: fever, no verbal output but response upon calling his name O: BP: 100/70-140/80 HR: 90-143bpm RR: 19-23cpm T: 37.4-39.8C
  62. 62. Skin:warmHEENT: anecteric, dilated R pupil (5mm) & non- reactive to light and half open.Neck:(-) LAD, no neck rigidityC/L: ECE, CBS, (+)rales both Lung field, (-)wheezeCVS: DHS, tachycardic, no murmurAbd.: flat, NABS, soft, nontender, no massExt. : No edema, strong pulses, w/ limitation in movement on the L side of the body.
  63. 63. A: HIV Infection, R/I CNS Infection (Toxoplasmosis vs. Lymphoma) UGIB probably 2ndary to Stress Ulcer, Herpes Zoster R ThighP: - continue all meds. - family opted to transfer to other hospital for further mgt.
  64. 64.  CD4 = 13.23  Markedly decrease T. (N.V 535-1451) Lymphocytes. CD8 = 68.82  Markedly decrease (n.v. 139-783) Helper T cells. CD4/CD8 = 0.2  Normal T-suppressant population.(N.V. 1.5:1-2.7:1)
  65. 65. HIV Confirmatory Test Toxoplasma Serologic Test CLEIA: Reactive IgG Ab to Toxoplasma Gondii Ag/Ab = 270.08 366.6 IU/mL – Reactive(N.V. >3.500)  IgG Ab to Toxoplasma Gondii = 0.49 IU/mL (n.v ≤0.600) negative
  66. 66. FINAL DIAGNOSISHuman Immunodeficiency Virus Positive 1 w/ Multiple Intracranial Enhancing Lesion (Toxoplasmosis), UGIB probably 2ndary to Stress Ulcers Gastropathy – Resolved. w/ Herpes Zoster, R Thigh - Resolved

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