The document reports on the morbidity and mortality cases from the Department of Family and Community Medicine at Perpetual Succour Hospital for August 2011, including statistics on hospital admissions, census in family medicine, leading causes of morbidity, and mortality cases. Internal medicine had the highest percentage of total admissions at 46%, while the top three leading causes of morbidity in family medicine were acute gastroenteritis, pneumonia, and urinary tract infections. The single mortality case was a 50-year-old female with invasive ductal carcinoma of the left breast.

1. Department of Family and Community Medicine
Perpetual Succour Hospital
MORBIDITY AND MORTALITY
AUGUST 2011

2. TOTAL HOSPITAL ADMISSIONS---
 Internal Medicine 46.0%
 Pediatrics 17.7%
 Obstetrics & Gynecology 13.0%
 Family Medicine 11.8%
 Surgery 11.3%

3. FAMILY MEDICINE CENSUS 152
 Adult Medicine 56%
 Pediatrics 24%
 Surgery 14%
 Obstetrics & Gynecology 6%

4.  Outpatient Cases 243
 Charity Cases
03
 House Cases
11
 Mortality case 01
 Community OPD Census
47

5. CO-MANAGED CASES*
 Internal Medicine 29
 Pediatrics 5
 Surgery
 Obstetrics & Gynecology 9

6. LEADING CAUSES OF MORBIDITIES IN FAMILY
MEDICINE (ADULTS)
1. Acute Gastroenteritis with Some Dehydration 08
2. Community Acquired Pneumonia, Moderate Risk 08
3. Urinary Tract Infection 08

7. HEENT 5
Acute Exudative Tonsillitis 3
With Urinary Tract Infection 1
With Systemic Viral Infection 1
 Recurrent Tonsillitis
With Drug-induced Gastritis and
Esophagitis sp UGIE 1
 Maxillary Sinusitis; Dyslipidemia 1

8. RESPIRATORY 14
Bronchial Asthma In Acute Exacerbation 2

9. RESPIRATORY 14
Community Acquired Pneumonia Moderate Risk
8
 With Atrial Septal Defect 1
With DM2; Dyslipidemia 1
Pulmonary tuberculosis
4
With Dyslipidemia; Hypertension 1
With Cholelithiasis 1
 With sp CVD Infarct Left MCA 1

10. RESPIRATORY 14
 Sepsis 2nd Lung Abscess with Empyema
Thoracis Right; sp Thoracentesis; sp CTT;
DM Type 2; Complicated Urinary Tract
Infection 1
 Sepsis2nd Community Acquired Pneumonia;
Chronic Kidney Disease 2nd Hypertensive
Nephropathy; Anemia 2nd Chronic Kidney
Disease sp Hemodialysis 1

11. RESPIRATORY 14
Upper Respiratory Tract Infection 3
 With Costochondritis 1
With Hepatitis B infection; UTI 1

12. CARDIOVASCULAR 9
 Acute Coronary Syndrome, NSTEMI;
Dyslipidemia; HCVD 1
 Coronary Artery Disease
2
 HCVD; DM2; S/P Coronary Angiogram
1
 HCVD; BPH 1

13. CARDIOVASCULAR 9
 Deep Venous Insufficiency; HCVD;
Dyslipidemia; Lumbar Radiculopathy L4-L5
1
Hypertensive Urgency 5
With Benign Prostatic Hyperplasia 1
With Dyslipidemia 2
With HCVD 2

14. GASTROENTEROLOGY 18
Acute Gastroenteritis With Moderate Dehydration 8
 With Acute Kidney Injury 2nd Dehydration on top of
Chronic Kidney Injury 2nd Hypertensive
Nephropathy; Hypertension Stage 2;
Urinary Tract Infection; Dyslipidemia 1
With Hypertension Stage 2 1
With Community Acquired Pneumonia MR;
HCVD 1

15. GASTROENTEROLOGY 18
Non Ulcer Dyspepsia
1
Acute Calculous Cholecystitis 4
 With DM2; HCVD 2
With Hepatitis A Infection 1

16. GASTROENTEROLOGY 18
Cholelithiasis; VHD-Mitral Regurgitation Mild;
Adenomyoma W/ Adenomyosis;
Multiple Myoma
1
Gastric Ulcer, Antrum sp UGI Endoscopy
1
 Multiple Diverticulosis With Diverticulitis;

17. GASTROENTEROLOGY 18
UGIB 2nd Erosive Gastritis And Duodenal Ulcer
sp UGIE; HCVD; DM2 1
 Non-ulcer Dyspepsia; Benign Prostatic
Hyperplasia; HCVD; Renal Cortical Cyst
Right; Dyslipidemia
1

18. NEPHROLOGY 11
 Anemia 2nd Chronic Kidney Disease 2nd
Chronic Glomerulonephritis sp IJ Catheter
insertion; S/P AV fistula creation 1
Chronic Kidney Disease 2nd Obstructive
Uropathy
2nd Tuberculous Cystitis; Dessiminated
Tuberculosis (Pott’s Disease)
1

19. NEPHROLOGY 11
Complicated Urinary tract infection 8
with DM type 2 1
with DM type 2; Hypertension Stage 2 1
with Cholelithiasis; Gastritis; DM2;
Hypertension Stage 1
1
with Nephrolithiasis, Right
1
with Nephrolithiasis, Left 1

20. INFECTIOUS DISEASE 10
Classical Dengue Fever 5
With Acute Exudative Tonsillitis 2
With Benign Prostatic Hyperplasia; GERD 1
Dengue Hemorrhagic Fever 1
Enteric Fever; Ethmoidal Sinusitis Left
1
Measles; Acute Tonsillopharyngitis 1
Viral Exanthem 2
With Renal Cyst,Left 1

21. NEUROLOGY 4
Acute Cerebrovascular Disease Infarct 3
 Right Lentiform Nucleus with HCVD; DM2 1
 Right Frontal, Right Caudate, Right Lentiform,
Both Thalami, Right Internal Capsule
And Pons With BPH; HCVD
1
 Left Lenticulocapsular Area And Left Corona
Radiata 1

22. NEUROLOGY 4
 Acute CVD Hemorrhage Left Thalamo-
Capsular Area Right; HCVD 1

23. ONCOLOGY 3
 Invasive Ductal Carcinoma left Breast Stage
IV
(Lung and Bone Metastasis) sp MRM(2002)
&
sp Chemotherapy (March2011)
1
 Adenocarcinoma Right Lung St IV
(Bone Metastasis)
1
 Squamous Cell Carcinoma Tongue Stage IV

24. MUSCULOSKELETAL 6
 Diabetic Foot Left with DM2; HCVD 1
 Diabetic Foot Right; DM2 1

25. MUSCULOSKELETAL 6
 Lumbosacral Radiculopathy 2nd Diffuse
Disc Bulge At L5-S1; Bilateral Carpal
Tunnel Syndrome; Dyslipidemia;
Overactive Bladder 2nd Perineural Cyst
S2 Area 1
Lumbar Radiculopathy 2nd Disc bulge L1-L2
1

26. MUSCULOSKELETAL 6
 Lumbosacral Radiculopathy sec to disc
dessication L5-S1 1
 Lumbosacral Radiculopathy sec to L4-L5,
L5-S1 disc bulge 1

27. IMMUNOLOGY 1
 Anemia 2nd Systemic Lupus Erythematosus;
SLE; PU 26wks AOG NIL 1

28. MORTALITY 1
 M.G. 50/F, Lilo-an
 Chief Complaint: dyspnea.
 Final Diagnosis: Invasive Ductal Carcinoma
Left Breast Stage IV
(with lung and bone metastases)
Date admitted: July 29, 2011
Date expired: August 5, 2011
No. of hospital days: 7

29. TAKE OFF CASE
 Patient Profile
 M. F. 60/M, Filipino, Roman
Catholic, Paknaan, Mandaue City
 Social/Past Medical History
 Smoker for >50 pack years, occasional alcoholic
beverage drinker
 (-) Food and Drug Allergies
 Previous Hospitalization: July 2011, PSH-
Pneumonia

30.  Chief Complaint: Dyspnea
 History of Present Illness
 9 days PTA – discharged with a diagnosis of
CAP moderate risk.
 4 hours PTA – noted onset of dyspnea on
exertion and backpain.
 2 hrs PTA – fever and dyspnea

31. PHYSICAL EXAMINATION
 V/S: BP110/50, PR 108, RR27, T38.9
 Skin: no lesions, warm, senile turgor
 HEENT: pinkish palpebral conjunctiva,
anicteric sclerae, (+) alar flaring, (-) neck vein
engorgement

32.  C/L: Equal Chest Expansion, Decreased
Tactile
Fremitus Right, Decreased Breath Sounds
Right Lung, (+) Rales Left Lung
 CVS: Tachycardic, Distinct Heart Sounds,
(-) Murmurs

33.  Abdomen: flat, normoactive bowels sounds,
(-) tenderness
 GUT: (-) kidney punch sign, bilateral
 Extremities: (-) edema, strong pulses,
(-) deformities

34. WORKING DIAGNOSIS
 CAP MR with Pleural Effusion Right
 Diabetes Mellitus type 2

35. ON ADMISSION
 O2 at 2LPM
 IVF was started at 20gtts/min.
 The following labs were taken.

36. ON ADMISSION
Labs: Urinalysis
CBC
Glucose ++
WBC 39.89
HGB 10.6 Protein +
HCT 31.9 Ketones +
Platelet 691
RBC 10-20
Neutrophils 96
WBC 5-10
Lymphocytes 2 Epith cells rare
Monocyte 2 Mucus rare
threads
Bacteria few

37. ON ADMISSION
ECG CXR Xray Lateral decubitus
Sinus Rhythm, Non- Pleural Effusion, Right Pleural Effusion, Right
specific ST-T wave ----- -------
changes

38.  Medications:
 Salbutamol + Ipratropium nebulization,
Paracetamol PO, Ranitidine IV, Meropenem IV,
Clindamycin IV, Metformin, Gliclazide, NaCl tab,
Erdosteine.
 Co-managed with a Pulmonologist

39.  Other Labs:
K 4.47
Na 121
Sputum Negative
AFB (3x)

40. 1ST HOSPITAL DAY
S: (+) Dyspnea, (+) fever
O: BP110/80-120/80, PR108-112, RR24-27,
T37.5-38.9, O2 Sat 89-91%
C/L: Equal Chest Expansion, decreased
breath sounds at the R lung field, (+)
rales
CVS: distinct heart sounds, tachycardic,
regular rhythm

41.  UTZ of Hemithorax (Marked and estimated):
 Axillary:
767 cc (5cm depth)
 Posterior: 697 cc (5cm depth)
 No existence of fibrous bands nor loculations
 Impression: Pleural effusion Right

42. Clotting time 10 mins
Protime C13/ p 15.1/ % activity 75%/ INR 1.21
Bleeding time 1 min
Blood type A+
CBS 159-201mg/dL

43.  Thoracentesis was done (450cc of foul-
smelling, purulent pleural fluid)
 Biopsy of pleural fluid: adequate cellularity,
abundant erythrocytes and moderate
lymphocytes. No tumor cells demonstrated.
 Sputum Gram stain showed Candida
albicans

44.  Blood Culture (2 diff sites): no growth after 5
days of incubation.
 Rpt CXR: Pleural effusion, Right

45. A: Empyema Thoracis Right Lung 2nd Lung
Abscess; DM2

46. P: Medications:
Meropenem IV, Ranitidine IV,
Salbutamol+Ipratropium nebulization q6h,
Metformin 500mg BID, Diamicron30mg OD
Clindamycin 300mg IV
Erdosteine 300mgPO BID
Paracetamol PO RTC.
O2 inhalation @4LPM
Referred to Cardiothoracic Surgeon for CTT.

47. 2ND HOSPITAL DAYS
S: (+) Dyspnea, (+) febrile episodes
O: V/S BP 110/70 – 120/80, PR 98-110,
RR 21-26, T 37.4 – 37.8, O2 sat 88- 92%
C/L: equal chest expansion, (+) rales
CVS: distinct heart sounds, Tachycardic

48.  CBS: 257-265mg/dl
 CTT was done: drained 800cc of purulent,
foul-smelling fluid.
 Rpt CXR: Resolving Right Pleural Effusion;
Pulmonary Congestion; Concomittant
Pneumonia is considered.; Right CTT in
place: Subcutaneous Emphysema Right;

49.  Pleural fluid cytology: Mixed acute and
chronic inflammation
 Pleural fluid cell block: adequate cellularity,
abundant erythrocytes and moderate
lymphocytes

50. A: Empyema thoracis secondary to Lung Abscess
sp Thoracentesis, sp CTT
P: Medications:
Salbutamol + Ipratropium nebulization q8hrs
Paracetamol PO PRN, Ranitidine IV, Meropenem
IV,
Clindamycin IV, Metformin, Gliclazide,
NaCl tab, Erdosteine.
Tramadol +Paracetamol tablet 1 tab q 6hrs RTC
Incentive spirometry

51. 3RD – 6TH DAY OF HOSPITALIZATION
S: (-) dyspnea, (+) febrile episodes
O: BP 120/80- 140/70, PR 102-112, RR21-24,
T 36.8- 37.9, O2 sat 90-94%; noted yellowish
to bloody CTT drain.
FBS 125.77mg/dL
Na 132
K 3.99
CBS 102 – 168mg/dL

52.  RPT CXR: Resolving Right Pleural effusion;
Resolving Pulmonary congestion;
concomittant pneumonia still considered;
Right CTT in place; Resolved subcutaneous
emphysema Right.
 2DED: 63% Concentric LV Remodelling W/
Adequate Contractility And Systolic Function
But W/ Doppler Evidence Of Diastolic
Dysfunction Grade 2.

53. A: Sepsis 2nd Lung Abscess w/ Empyema
Thoracis
and Pulmonary Congestion sp Thoracentesis;
sp CTT
P: Furosemide 40mg IVTT 2 doses were given.
Clindamycin IV was shifted to Clindamycin
300mg 1 cap q6hrs po.

54.  Other meds continued:
Salbutamol + Ipratropium nebulization q12h
PRN, Paracetamol PO, Meropenem IV,
Metformin, Gliclazide, NaCl tab, Erdosteine.
 Tramadol +Paracetamol tablet 1 tab q 6hrs
RTC
 Conzace 1 capsule OD PO
 Continue incentive spirometry

55. 7TH – 10TH HOSPITAL DAY
S: (-) dyspnea, (-) febrile episodes
O: BP 130/80, PR 82-88, RR 21-23, T 36 36.2, O2 sat
94-95%;
 <100cc of pleural fluid/day.
 PPD test: negative after 48-72hrs
 Pleural fluid anaerobic culture: Anaerobic Streptococcus
 CBS: 90 – 168mg/dL
A: Resolving Pleural Effusion Right;
Resolving Pulmonary Congestion

56. P: IVF terminated and changed to heplock;
 Decreased O2 inhalation at 2LPM then
discontinued.
 Clindamycin PO was increased to 300mg 2
caps q6hrs;
 Paracetamol+tramadol tablets was dec to q8 PRN
 Last dose of NaCL tablet was given.
Other meds were continued.
Chest tube was removed.

57. 10TH HOSPITAL DAY
S: (-) dyspnea, (-) fever
O: BP 120/70- 140/80, PR 78-96, RR 20-23, T
36.0-36.2.
CBS: 136mg/dL
A: Stable
P: patient was discharged w/ home meds:
Metformin 850mg BID PO pc meals
Gliclazide 30mg OD PO ac Breakfast
Conzace 1 capsule OD PO

58.  Home meds:
 Meropenem 1g heplock for 5 days to complete 2
weeks then shift to Co-amox 625mg tab TID PO
for 6 weeks
 Clindamycin 300mg 2 capsules TID x 5 weeks to
complete 6 weeks

59. FINAL DIAGNOSIS
1. Sepsis secondary to Lung Abscess w/
Empyema Thoracis Right; S/P
Thoracentesis, Right, S/P CTT, Lysis of
loculations, Pleural lavage, Right under
fluoroscopic Guidance
2. Diabetes Mellitus type 2

60. THANK YOU!!!