Mortality Conference- montemar edited.pptx

Morbidity and Mortality
Conference
October 15, 2020
Joma Criselle B. Zara-Yasol, MD / Jennifer P. Aglugub, MD
Reisdents-in-charge
Ma. Star E. Esguerra, MD, FPOGS
Consultant-in-charge
Republic of the Philippines
Department of Health
SOUTHERN ISABELA MEDICAL CENTER
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

GENERAL DATA
• M. M.
• 20 y/o
• Female
• Filipino
• Married
• Roman, Catholic
• Gravida 1 Para 1 (1-0-0-1)
• Reina Mercedes, Isabela
• Admitted for the first time at Southern Isabela Medical
Center on October 02, 2020, at 3:30 pm

CHIEF COMPLAINT
Difficulty of Breathing

HISTORY OF PRESENT ILLNESS
11 days PTA
- patient had an imminent vaginal delivery at Cauayan
District Hospital
- uneventful
- the rest of hospital stay was unremarkable
- discharged improved on hospital day 2
- Home meds:
1. Cefalexin 500 mg tab every 8 hours for 1 week
2. Mefenamic Acid 500 mg cap every 8 hours for pain

8 days PTA
- started to have episodes of dyspnea
- easy fatigability
- relieved by resting
- no consultation was done nor medications taken.

Morning PTA
- worsening of dyspnea
- with associated shortness of breath
- rushed to Reina Mercedes RHU with noted BP of 80/60,
tachypneic and tachycardic.
- was hooked to O2 support, then was subsequently
referred in this institution for further evaluation and
management.

PAST MEDICAL HISTORY
• No history of previous hospitalization
• No history of diabetes mellitus, bronchial asthma,
pulmonary tuberculosis, liver, and kidney diseases.
• No history of accidents, trauma, major illness, blood
transfusion or exposure to radiation and toxic chemicals

FAMILY HISTORY
• (+) Bronchial asthma - father
• (-) Hypertension
• (-) Diabetes mellitus
• (-) Pulmonary tuberculosis,
• (-) Cardac disease
• (-) Liver disease
• (-) Kidney disease

PERSONAL and SOCIAL HISTORY
• Non-smoker
• Non-alcoholic beverage drinker
• No history of illicit drug use
• No known allergies to food and drugs

OBSTETRIC & GYNECOLOGIC
HISTORY
• M – 13 y/o
• I – regular
• D – 4-6 days
• A – 4 ppd
• S – (-) PMS
• Coitarche: 19 y/o
• No. of sexual partner: 1
• STI: None
• FP: None
Gravida 1 Para 1 (1001)
• 11th day post-partum
• NSD with RMLE - CDH
• FT, LBG (3050 gm)
assisted by a midwife,
uncomplicated

PRENATAL HISTORY
First Trimester
- had cessation of menses, dizziness, nausea and
vomiting.
- Pregnancy test: Positive
- 2nd month of pregnancy (February 2020), she had her
first PNCU at RHU Reina Mercedes.
- No other subjective complaints such as hypogastric pain,
vaginal discharge, vaginal spotting, dysuria and fever.
- started on Folic Acid a cap once a day, which she took
regularly.

PRENATAL HISTORY
Second Trimester
- 2nd PNCU at 30 weeks of pregnancy (July 2020) at the
same Rural Health Unit.
- No unsusual subjective complaints
- Patient was given Ferrous sulphate 1 tablet once a day
and multivitamins tablet once a day.
- Diagnostic examinations such as CBC, urinalysis and
ultrasound were requested, but was lost to follow up.

PRENATAL HISTORY
Third Trimester
- due to the pandemic, patient was not able to come for a
follow up prenatal check
- was rushed in Cauayan District Hospital in imminent
delivery at 38 to 39 weeks AOG, delivering to a live baby
girl, Birth Weight of 3,050 gm, AS 8,9; AGA.
- Delivery was uneventful
- discharged improved after 2 days of hospital stay.

REVIEW OF SYSTEMS
CONSTITUTIONAL No fever, no chills, with malaise, no weight loss
HEMATOLOGY No easy bruisability
CNS No headache, with dizziness, no seizure, no
loss of consciousness
HEENT No blurring of vision, no hearing loss, no tinnitus
RESPIRATORY No cough, no colds, no apnea
GIT No vomiting, no diarrhea, no constipation
GUT No dysuria, no urinary frequency, no urgency
NMS No arthralgia, no myalgia, no numbness

PHYSICAL EXAMINATION
General survey: Conscious, coherent, in cardiorespiratory distress
Vital signs: BP: 110/60 mmHg HR: 123 bpm RR: 32 cpm Temp: 36.4 C
O2 Saturation: 94% at room air
Weight: 42.5 kg Ht: 5'0 BMI: 18.5 (underweight)
SKIN Cold clammy, pale looking, no jaundice, no cyanosis, no
lesions
HEENT: Pale palpebral conjunctiva, anicteric sclera, no
nasoaural discharge, no tonsillopharyngeal congestion
Neck: Supple, no neck vein engorgement,
no palpable lymph nodes
Breast: Symmetrical contour, no dimpling, no palpable mass,
no abnormal nipple discharge

PHYSICAL EXAMINATION
Chest: Symmetrical chest expansion, with retractions, clear
breath sounds
Heart: Adynamic precordium, tachycardic, regular rhythm, no
murmur
Abdomen: Flat, with normoactive bowel sounds, no hypogastric mass
nor tenderness
Pelvic Exam: Normal looking external genitalia, with intact perineal repair
Speculum Exam: Not done
Internal exam cervix closed, midline, firm, uterus slightly enlarged, no
palpable adnexal mass/ tenderness,
(+) yellowish-brownish foul smelling vaginal discharge
Digital rectal exam: Not done
Extremities: No gross deformities, with full and equal pulses, with
bipedal edema, Grade 1, non-pitting

SALIENT FEATURES
• 20 y/o
• G1 P1 (1001)
• s/p NSD, Post partum Day 11
• Difficulty of breathing
• Shortness of breath
• Tachycardic
• Tachypneic
• (+) Bipedal edema

ADMITTING DIAGNOSIS
• Gravida 1 Para 1 (1001)
• s/p Normal Spontaneous Delivery, Post partum Day 11;
• t/c Post partum cardiomyopathy;
• Covid Suspect - moderate

UPON ADMISSION
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
(+) difficulty of
breathing
(+) shortness of
breath
(-) chest pain/
tightness
(-) cough
(-) colds
(-) fever
(-) profuse vaginal
bleeding
(-) hypogastric pain
BP 100/60mmHg
CR 123
RR 32
T 36.4
O2 sat- 89-92% at room air
94% with O2 supprt
Symmetrical chest
expansion, with retractions,
Clear breath sounds
Adynamic precordium,
(-) murmur
IE: cervix closed, uterus
slightly enlarged, with
yellowish-brownish foul
smelling vaginal discharge
s/p/ NSD, Post partum
Day 11;
T/C Post partum
cardiomyopathy;
Covid Suspect- Moderate
Diet:
-NPO temporarily
Diagnostics:
- CBC with PC
- Blood Typing with RH,
- HBsAg
- Syphilis
- Creatinine
- ALT, AST
- Na, K
- 12 L-ECG
- CXR-AP sitting
- 2D-echo with doppler
- OPS/ NPS PCR
IV access: Heplock

UPON ADMISSION
s/p/ NSD, Post partum
Day 11;
T/C Post partum
cardiomyopathy;
Covid Suspect- Moderate
Medications:
- Furosemide 20mg IV
- Ampicillin 1g IV q8
- Gentamycin 240mg
IV OD
- Metronidazole 500
mg IV q8
- IFC inserted
- O2 via NC at 5Lpm
- moderate to high
back rest
- VS monitoring q1
until stable
- referred to IM for
further evaluation &
co-management

UPON ADMISSION
IM notes:
(+) easy fatigability
associated with
dyspnea
(+) 2 pillow
orthopnea
(-)cough
(-) colds
(-)fever
Awake, coherent, NICRD
(+) slightly pale palpebral
conjuctiva, (-) NVE
Symmetrical chest
expansion
No retractions
(+) wheezes,
(-) crackles
Adynamic precordium, (-)
murmur
(+) Bipedal edema Grade 1
Bronchial Asthma in Acute
Exacerbation;
Peripartum
Cardiomyopathy
T/C CHF IIIB;
Covid Suspect- Severe
Additional Diagnostics:
- Vaginal GS/CS
- RBS
- Serum ferritin
- ABG
- LDH
- iCa, Mg
Medications:
-Hydrocotisone 100mg IV q8 x
3 doses
-Furosemide 20 mg IV q8 x 3
doses
I&O monitoring

5th HOUR of HOSPITAL STAY
(+) decreased
dyspnea
Awake, coherent,
NICRD
OB diagnosis:
S/P Normal Spontaneous
Delivery, Post partum
Day 11; T/C Post partum
cardiomyopathy; Covid
Suspect- Moderate
IM diagnosis:
Bronchial Asthma in
Acute Exacerbation
Peripartum
Cardiomyopathy
T/C CHF IIIB; Covid
Suspect- Severe
- May have DAT with SAP

HOSPITAL DAY 1
OB Notes:
(+) decreased
dyspnea
(-) chest
tightness/ chest
pain
(-) palpitations
IM notes:
(+) decrease
dyspnea
(+) orthopnea
(-) palpitations
Awake, coherent,
NICRD
Vital Signs:
BP: 100/70mmHg
CR: 98 bpm
RR:25 cpm
T: 36.5C
OB diagnosis:
Gravida 1 Para 1
(1001) S/P Normal
Spontaneous Delivery,
Post partum Day 12;
T/C Post partum
cardiomyopathy;
Covid Suspect-
Severe
IM diagnosis:
Bronchial Asthma in
Acute Exacerbation
Peripartum
Cardiomyopathy
T/C CHF IIIB; Covid
Suspect- Severe
- Continue present
meds
- O2 support as
needed
- Facilitate 2d-Echo
with doppler
- Awaits OPS/NPS
result
- For serum
albumin, TSH, FT4

HOSPITAL DAY 2
OB Notes:
(-) dyspnea
(-) vaginal discharge
(-) hypogatric pain
IM notes:
(+) decreased
dyspnea
(+) bibasal rales
(+) Grade 2 bipedal
edema
Vital Signs:
BP: 80-90/60mmHg
CR: 98 bpm
RR:25 cpm
T: 36.5C
OB diagnosis:
Suspect- Severe
IM diagnosis:
Bronchial Asthma in
Acute Exacerbation
Peripartum
Cardiomyopathy
T/C CHF IIIB; Covid
Suspect- Severe
- Still for 2d-Echo with
doppler
- -Awaits OPS/NPS
result
-Furosemide 20 mg TIV
Q8 to round the clock
-For serum K tomorrow
-Facilitate 2D echo with
doppler studies

HOSPITAL DAY 3
OB Notes:
(-) dyspnea
(-) chest tightness
(+) decrease bipedal
edema
IM notes:
(-) dyspnea
(-) orthopnea
(-) palpitations
(+) bipedal edema
(+) occasional
crackles
Vital Signs:
BP: 90/60 mmHg
CR: 98 bpm
RR:20 cpm
T: 36.5C
Suspect- Severe
Bronchial Asthma in
Acute Exacerbation
Peripartum
Cardiomyopathy
T/C CHF IIIB;
NCov PCR- negative
- continue present
management
- awaiting swab result
- for serum K, as
previously ordered
-Transfer to OB stepdown
ward
- Revise Furosemide 20
mg IV to q 12 with BP
precaution
- Facilitate 2D-echo with
doppler
- Lanoxin ½ amp IV now
then 0.25 mg tab, ½ tab
OD

HOSPITAL DAY 3 (11:12 PM)
OB Notes:
(+) seizure episode
(+) headache
(+) pallor
(-) DOB
(+) bipedal edema
IM notes:
(+) mild headache
Vital Signs:
BP: 110/70 80/60mmHg
CR: 90 bpm
RR:20 cpm
T: 36.5C
O2 sat- 98%
cardiomyopathy; NCov
PCR- negative
Bronchial Asthma in
Acute Exacerbation
Peripartum
Cardiomyopathy
T/C CHF IIIB; NCov PCR-
negative
- Place patient in
tendelenburg position
-02 inhalation at 3 lpm
-Stat CBC
-facilitate 2D-echo with
doppler
-for stat CBC, Na, K, Ca,
RBS  145
-Paracetamol 300mg IV
now
-inform IM
- agreed w/ Paracetamol
- serum Mg
- Diazepam 1 amp IV
PRN for active seizure

HOSPITAL DAY 4
IM notes: Vital Signs:
BP: 80/60mmHg
HR 98 bpm
RR: 22 cpm
O2 sat: 98%
Bronchial Asthma in Acute
Exacerbation
Peripartum
Cardiomyopathy
T/C CHF IIIB;
NCov PCR- negative
-Norepinephrine drip:
Norepinephrine 10 mg
+ 90 cc of PNSS as
main line to start at
5cc/hr

HOSPITAL DAY 4
OB Notes:
(+) dyspnea
IM (IDS) notes:
(+) tachypnea
(-) desaturations
Vital Signs:
BP: 80/60mmHg
CR: 99 bpm
RR: 20 cpm
T: 36.5C
O2 sat- 99%
(+) neck vein engorgement
(+) wheezes Bilateral mid
to base
Cxray- pulmonary
congestion
PCR- negative
Bronchial Asthma in
Acute Exacerbation
Peripartum
Cardiomyopathy
T/C CHF IIIB; NCov PCR-
negative
- still for 2D-echo
- maintain on O2 support
- maintain on moderate
high back rest
- WOF seizure episodes
- no active IDS
management at the
moment, for self isolation
(Oct 6-16, 2020)
- refer to gen IM for co-
management
- Combivent neb 1 neb
q15 x 3 doses

HOSPITAL DAY 4
IM notes:
(+) DOB
(-) chest pain
Vital Signs:
BP: 80/60mmHg
CR: 92 bpm
RR:22 cpm
T: 36.4C
O2 sat- 98%
(-) rales
(-) crackles
(-) wheezes
(-) murmur
(-) edema
Peripartum Cardiomyopathy
T/C Pulmonary Hypertesion;
NCov PCR- negative
- for repeat CXR,
- 12 L-ECG,
- follow up 2D-echo with
doppler result
- strict I&O monitoring
- For repeat AST, ALT, - -
- Creatinine, FT3
- Calcium gluconate 1 am
SIVP q6 x 2 doses
- for repeat I Ca post
correction
- PNSS 40 ml/ hr

HOSPITAL DAY 4 (3:36 AM)
IM notes:
(+) chest pain
(+) tachycardia
Vital Signs:
BP: 70/50mmHg
CR: 120bpm
RR:22 cpm
T: 36.4C
O2 sat- 96%
Peripartum
Cardiomyopathy
T/C Pulmonary
Hypertension;
NCov PCR- negative
- Paracetamol 600 mg
IV now
- Lanoxin 0.25 mg IV
now
- Start KCl drip (20meq
KCL + D5W thru IV
infusion
- Repeat serum K now

HOSPITAL DAY 5
OB Notes:
(+) dyspnea
(+) chest pain
(+) labored breathing
IM notes:
Vital Signs:
BP: unappreciated
CR: 110 bpm
RR: 28 cpm
T: 36.5C
O2 sat- 97%
PCR- negative
Peripartum
Cardiomyopathy
T/C Pulmonary
Hypertension;
NCov PCR- negative
- refer back to IM
- ff-up 2D- echo result
Maintain on O2 support
- Suggest transfer patient
to ICU
- follow up 2D-echo with
Doppler result
- Give Digoxin 1 amp IV
now

HOSPITAL DAY 5 (10:50 AM)
OB Notes:
(+) dyspnea
(+) chest pain
Vital Signs:
BP:80/60 mmHg
CR: 110 bpm
RR: 28 cpm
T: 36.5C
O2 sat- 97%
IE: cervix is closed, uterus
slightly enlarged, (+)
mucoid-blood tinged
vaginal discharge, non-foul
smelling
PCR- negative
- for transfer of service to
IM

IM notes:
(+) chest pain
(+) tachycardia
Vital Signs:
BP: 70/40mmHg
CR: 94bpm
RR: 26 cpm
T: 36.5C
O2 sat- 96%
Peripartum
Cardiomyopathy
T/C Pulmonary
Hypertension;
NCov PCR- negative
-Shift Digoxin to 1 amp IV
OD
-Dobutamine drip: D5W
250 ml + 2 amps
Dobutamine to start at
2ugtts/min
-follow up 2D- echo with
doppler result
-Calcium gluconate 1
amp SIVP q4 x 4 doses
-for repeat iCa post
correction
-referred to IM-cardio
-for CKMB, trop I

IM-Cardio notes:
(+) chest pain
(+) tachycardia
Vital Signs:
BP: 70/40mmHg
CR: 96 bpm
RR: 28 cpm
T: 36.4C
O2 sat- 96%
12L-ECG: sinus
tachycardia, Right
axis deviation,
RVH, RAH
Cardiogenic Shock
probably secondary
to pulmonary
embolism
Covid Negative
- suggest to transfer to ICU
- follow up 2D echo with
doppler
Review of medications:
- Lanoxin 0.25 mg 1 amp IV
OD
- Dobutamine 2 amps in 250 cc
D5W titrate on 3 cc/hour to
reach BP 90/60
- Norepinephrine drip titrate by
5cc/ hour to reach BP 90/60
-Start enoxaparin 0.4 cc SQ
BID
-for D-dimer, CKMB, Trop I

IM notes:
(+) tonic clonic
seizure then
subsequently
arrested
Vital Signs:
BP: 0
CR: 0
RR: 0 T
T: 36.5
Working Diagnosis:
1. t/c Peripartum
Cardiomyopathy
2. t/c Pulmonary
Hypertension;
3. Endometritis
4. Seizure disorder
- CPR initiated
- Stat intubation done
- for transfer to ICU
- for NGT
- Epinephrine 1 dose was
given
-Osteorized feeding
1400Kcal in 6 divided
doses via NGT
- for repeat serum Na, Mg
-Diazepam 5mg IV PRN for
seizure
-Phenytoin 10mg IV q8

OB notes:
(+) arrested
6:05 PM
IM notes:
Vital Signs:
BP: 0
CR: 0
RR: T
T:
Persistent asytole
S/P Normal
Spontaneous Delivery,
Post partum Day 16; T/C
Post partum
PCR- negative
Cardiogenic shock
secondary to Acute
Pulmonary Embolism;
Post partum
cardiomyopathy
S/P NSD; post-partum
Day 16
NCov PCR- negative
- Continue CPR
- Epinephrine 1 amp IV every 3
mins x 8 doses
- pronounced dead
- Post-mortem care
For 12L-ECG

FINAL DIAGNOSIS
Cardiogenic Shock secondary to Acute Pulmonary Embolism;
Post partum Cardiomyopathy;
s/p Normal Spontaneous Delivery, Post partum Day 16;
NCov PCR-negative

COMPLETE BLOOD COUNT
Parameters Normal Range Oct 02, 2020 Oct 05, 2020
WBC 4.0 – 10.0 x 109/L 14.24 13.63
Neu 50.0 – 70.0 78.9 65.3
Lym 20.0 – 40.0 15.3 28.1
Mono 3.0 – 12.0 4.8 5.0
Eos 0.5 – 5.0 0.4 1.1
Bas 0.0 – 1.0 0.6 0.4
RBC 3.5 – 5.0 x 1012/L 4.06 3.61
Hgb 11.0 – 15.0 g/dL 12.1 10.5
Hct 37.0 – 47.0 % 36.8 32.1
Plt 150 – 450 x 109/L 401 329
Blood Type AB Rh positive

Normal Value Oct 02 Oct 03 Oct 05 Oct 06 Oct 07
RBS 70.0-115.0 mg/dL 94.4 145.0
Sodium 135.0-145.0 mmol/L 134.7
Potassium 3.5-5.10 mmol/L 4.73 3.91 4.74
Magnesium 0.7-1.0 mmol/L 0.9
I Calcium 1.05-1.25 mg/dL 0.903 0.921
Creatinine 62.0-133.0 umol/L 97.7 92.4
ALT 0-35 u/L 222 78
AST 14-59 u/L 243 53
LDH 313-618 U/L 834
Albumin 90-60 mg/dL 27.5
FT3 4.26 - 8.10 pmol/L 4.76
FT4 10.0 - 28.2 pmol/L 28.5
TSH 0.645 - 4.68 mIU/L 0.607
CKMB Not done
Trop I Not done
D-Dimer Not done
BLOOD CHEMISTRY

CHEST X-RAY
October 02, 2020
No active lung infiltrate seen.
The main pulmonary artery is mildly dilated.
Heart is mildly enlarged (CTR: 0.55)
Diaphragm, costophrenic sulci and bony thorax
are unremarkable
IMPRESSION:
Mild cardiomegaly with signs of pulmonary
hypertension.
October 06, 2020
Follow up study again shows no active lung infiltrate.
The main pulmonary artery remains prominent.
Heart is enlarged.
Diaphragm, costophrenic sulci and thoracic cage
structures are intact.
IMPRESSION:
Cardiomegaly with signs of pulmonary hypertension, as
before.

12-LEAD ECG
October 02, 2020 Sinus tachycardia
Possible right atrial abnormality
Marked right axis deviation
Possible right ventricular hypertrophy
Borderline ECG
October 07, 2020 Atrial fibrillation with rapid ventricular response
Right axis deviation
Possible right ventricular hypertrophy
Lateral ST elevation suggests early repolarization
Inferior ST-T abnormality is probably due to ventricular hypertrophy
Consider Acute STEMI
Abnormal ECG

2D ECHO with DOPPLER
(October 06, 2020)
INTERPRETATION
Normal left ventricular dimension with global hypokinesia, with moderate systolic dysfunction.
The right ventricle is normal in dimension with good wall motion and contractility.
The left atrium is normal with no evidence of thrombus.
The anterior and posterior mitral valve leaflets are normal with no restriction of motion. The annulus is normal.
The anterior and septal tricuspid valve leaflets are normal with no restriction of motion. The annulus is normal.
The right coronary cusp, non-coronary cusp and left coronary cusp of the aortic valve are normal with no no restriction of
motion. The annulus is normal.
The pulmonic valve is normal in dimension.
The main pulmonary artery and aortic root are normal in dimension.
The pericardium is normal.
DOPPLER
Mosaic color flow noted across the mitral, tricuspid and pulmonic valves.
Pilmonary artery pressure of 35 mmHg by PAT, 46 mmHg by TR jet.
CONCLUSION
Normal left ventricle with global hypokinesia with moderate systolic dysfunction.
Mild mitral regurgitation and tricuspid regurgitation.
Moderate pulmonary hypertension with mild pulmonary regurgitation.

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