CASE MANAGEMENT

REPORTS AND
PRESENTATIONS
CASE MANAGEMENT
CONFERENCES

Oliver Malimban Medicine

 6/9/2018

General Objective
Clinical Management
Conference To be able to accurately diagnose and
properly manage a patient with acute
De Leon, Adrian post-streptococcal glomerulonephritis.
Fortuno, Karen
Gallarzan, Czarinna
Malimban, Oliver

July 13, 2017

Specific Objectives Outline

• To be able to gather pertinent information ● History
from history and physical examination. ○ History of Present Illness
○ Review of Systems
• To be able to formulate and discuss ○
○
Birth and Maternal
Past Medical History
differential diagnosis logically from ○ Family History
○ Nutritional History
history and PE. ○ Immunization History
○ Developmental History
• To be able to make a plan a ○ Personal and Social History
○ Environmental History
management appropriately. ● Physical Examination
● Differential Diagnosis
● Assessment
● Plan of Management

General Data History of Present Illness

M.S., 6 year old, female, Filipino, Roman Catholic, born

on March 25, 2011 at Dasmariñas, Cavite and currently • 5 days PTA
residing in Dasmariñas, Cavite, was admitted for the 1st •(+) sore throat
•(+) dysphagia to solids and then to liquids
time at DLSUMC on July 4, 2017 at 11:42 pm. •(-) fever, cough, colds, diarrhea, abdominal pain
•no consult done
•given Erythromycin syrup (34 mkd) without prescription
which relieved sore throat
Chief Complaint: Abdominal Pain

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History of Present Illness History of Present Illness

• 4 days PTA • 3 days PTA

•(+) non-productive cough
•(+) undocumented fever •(+) colds - thick, whitish discharge
•(+) non-productive cough •(+) facial swelling and periorbital edema
•(-) colds, diarrhea, abdominal pain, headache, vomiting •(-) fever, diarrhea, abdominal pain, vomiting, dysuria,hematuria
•no consult done •(-) difficulty of breathing, orthopnea
•given Erythromycin syrup (34 mkD) and Paracetamol syrup (15 •no consult done
mkd) without prescription which relieved the fever
•cough was persistent •continued taking Erythromycin syrup (34 mkD) and
Paracetamol syrup (15 mkd) without prescription which
relieved the fever

History of Present Illness History of Present Illness

• 2 days PTA
•(+) non- productive cough - • 1 day PTA
•(+) colds - thick, whitish discharge •(+) non- productive cough -
•(+) facial swelling and periorbital edema •(+) colds - thick, whitish discharge
•(+) vomiting - previously ingested food, billous, non-greenish, •(+) facial swelling and periorbital edema
non-bloody •(+) vomiting - post-prandial
•(+) epigastric pain - intermittent •(+) abdominal pain- RLQ, intermittent, relieved by hot
•Consult with a General Practitioner compression
•prescribed with Cefuroxime (38 mkD) and Cetirizine (1mg/mL 5 •no medications taken
mL OD)- did not relieve vomiting, abdominal pain and cough

History of Present Illness Review of

Systems

• on the day of consult:

•(+) non- productive cough -
•(+) colds - thick, whitish discharge
•(+) facial swelling and periorbital edema
•(+) vomiting - post-prandial
•(+) abdominal pain- RLQ, intermittent, relieved by hot
compression
•consult to Pagamutan ng Dasma
•Referred to DLSUMC due to lack of Pediatric Nephrologist

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Birth and Maternal Past Medical History

Prenatal ● 39 y.o G5 P4 (4014)
● 10 prenatal checkups
● (+) UTI at 24 weeks AOG, took unrecalled medications (tablet)
for 7 days
● (-) hypertension, asthma, diabetes, spotting
● (-) exposure to toxigens: alcohol, cigarette, radiation
● work-ups: Ultrasound and CBC with allegedly normal results,
Urinalysis which revealed UTI March 2017: Measles
● no hospitalzation
● medications: folic acid ferrous sulfate, calcium May 2017: Mumps; no medications taken
Perinatal ● unrecalled number of hours of labor
● no complications noted • (-) TB, allergies, asthma, pneumonia
Postnatal ● born term via VSD
● lying-in clinic attended by a midwife
• (-) history of hospitalization and operations
● no problems after delivery such as cyanosis,jaundice and poor
activity • currently taking Multivitamins (Nutroplex and Ceelin)
● Newborn screening not done

Family History Nutritional History

• exclusively breastfed for 1 month

(+) Paternal: asthma, hypertension • formula fed until 1 year old
(-) Diabetes, TB, Cancer, kidney diseases • complementary feeding at 4 months
• table food at 6 months
• fond of eating junk foods and softdrinks

Immunization History
Developmental History
• allegedly complete from the health center
The patient is at par with age. The mother has no developmental
concerns regarding the development of her daughter.

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Personal and Social History Environmental History

• mother (39 y.o.), father (45 y.o.) both messengers

• lives near the river
• lives with parents, 3 siblings, grandmother
(primary caregiver) • frequently exposed to environmental smoke
• the 3rd in 4 children (burnt garbage)

• siblings had previous cough and colds
• exposed to gadgets at 1 year of age; screen
time: up to 2 hours per day
• other activities: playing with other children
• pets at home (pig, dog, chicken)
• garbage not segregated, not collected, thrown
into the river
• tap water for drinking

Physical Examination
General Survey

• General Survey
• Vital Signs
• Patient is well developed, well nourished, conscious,
• Anthropometrics and coherent, appears her chronological age of 6-
• Growth Chart Classification years and is not in cardio-respiratory distress.

Vital Signs Anthropometrics

Other measurements:
Abdominal circumference: 56.5 cm

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Growth Chart Classification

Weight-for-age: +1 (Normal)
Height-for-age: 0 (Normal)
BMI-for-age: 0 (Normal)

Interpretation: Not wasted, Not stunted

Weight-for-age: +1 (Normal)

Height-for-age: 0 (Normal) BMI-for-age: 0 (Normal)

Physical Examination Skin

Inspection
(+) fair skin
color (-) mass
Regional Examination:
(-) swelling
• Skin (-) clubbing
• HEENT: (+)hypopigmentation at trunk and extremities

• Chest and Lungs: (+) erythematous papular rash at the lower

extremities (-) cyanosis, jaundice
• Heart: (-) pallor
• Abdomen
• Extremities: Palpation
(+)moist and smooth skin
• Neurologic: (+)good skin turgor
(+)good capillary refill, 1-2 seconds

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Inspection
Head and Neck (+) symmetrical Eyes
(+)reactive pupils (3-4mm)
(+)periorbital edema
Inspection (-) sunken eyeballs
(+) black hair color (+) pink conjunctiva
(+) fair amount of hair with normal distribution (-) cornea or lens opacities
(+) normocephalic (-) nasolacrimal duct swelling, mass, discharge
(+) facial swelling
EOM Movements:
Duction
Palpation Version
(+) submandibular and anterior cervical
lymphadenopathy with tenderness

Tonometry: OD: Soft OS: Soft

Nose Oral Cavity and Pharynx

Inspection
(+) symmetrical
(+) patent
(-) mass, lesions Inspection
(+)midline nasal Lips: (+) symmetrical; (-) mass, lesions; (-) mouth ulceration
septum (-) discharge
(+)pinkish and moist oral mucosa and gums
Ears (+)tongue is in midline
(-) hyperemic tonsils
Inspection
(+) hypertophic tonsils (Grade
(+) symmetrical
II) (-) cleft or lip palate
(+) patent
(-) mucosal bleeding
(+) scanty cerumen on both ears
(+) intact tympanic membrane
(-) mass, lesions, deformity, tenderness, discharge

Chest and Cardiovascular

Inspection
(+) symmetrical chest
and chest expansion (-)
deformities
(-) use of accessory muscles
(-) retractions
(-) prominent veins
Palpation
Equal thoracic expansion
Equal tactile fremitus
Lungs Inspection
(-) precordial bulge
(-) visible pulsations
PMI at between 4th ICS medial to LMCL
Percussion
Resonant on all lung fields Palpation
Apex beat at the 4th ICS anterior axillary line
(-) heaves/ thrills
Auscultation
Clear and equal breath Auscultation
sounds (-) coarse crackles S1 > S2 on the apex, S1 < S2 on the base
(-) rhonchi normal heart rate of 101, regular rhythm
(-) murmurs
(-) wheezes

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Abdomen Abdomen
Palpation
Inspection (+)soft abdomen
Globular, non-distended, symmetrical with inverted (+) direct tenderness on the L lower
umbilicus quadrant (-) guarding
(-) scar, discoloration, lesions, visible mass, visible
peristalsis nor visible pulsations Percussion
(+) tympanitic all over four quadrants
Auscultation
Low pitched, normoactive bowel sounds at 15 Special Maneuvers
(+) bilateral CVA tenderness
bowel sounds per minute
Liver span: 7cm

Musculoskeletal
Neurologic Examinations

(-) swelling
• Mental Status Examination
(-) deformity
(-) mass • Cranial Nerves
(-) edema • Motor System
(-) limitation of motion • Reflexes
(-) tenderness • Sensory
Full and equal pulses • Cerebellar Exam
• Higher Cortical Function Testing
• Meningeal Testing

Mental Status Examination Cranial Nerves

The patient is quiet, neat, and is dressed appropriately according

to her age. The patient’s stream of talk was noted to be limited.
Mood was noted to be euthymic and with appropriate affect. The
patient is awake, conscious, coherent, with good attention span,
and is oriented to time, place and person.

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Reflexes Sensory

Touch and Pain:

Biceps Reflex 2/5

Triceps Reflex 2/5
Brachioradialis 2/5
Patellar Reflex 2/5

INITIAL IMPRESSION
Cerebellar POST STREPTOCOCCAL ACUTE
Exam GLOMERULONEPHRITIS
Bases
(-) Nystagmus
History Physical Examination
Finger to nose test (-) dysmetria
6 year old Hypertension - BP=130/100 mmHg
Epigastric tenderness Tachypnea - RR=36cpm
Sore throat and dysphagia Abdominal circumference: 56.5cm
Higher Cortical Function Testing Fever (+) Erythematous Papular Rash at the
Facial swelling lower extremities
(-) Aphasia Periorbital edema (+) Facial swelling
(-) Apraxia Vomiting (+) Periorbital edema
(+) Hypertrophic tonsils (Grade II)
(-) Agnosia (+) Submandibular and anterior
cervical lymphadenopathy
Meningeal (+) Globular abdomen
(+) Direct tenderness on the Left
Testing lower abdomen
(+) Bilateral CVA tenderness
(-) Brudzinski’s sign
(-) Kernig’s sign

Non-Renal
Rule-in Rule-out

Differential Diagnosis
1.Hemolytic Anemia Hematuria (-) organomegaly
(-) hepatomegaly

Renal Non-Renal
2.Hepatitis Edema (-) jaundice
(-) hepatomegaly

Infectious Non Infectious 3. Sub-acute bacterial (+) streptococcal infection (-) murmur
endocarditis (+) edema (-) easy fatigability
(-) dyspnea

Nephrotic Nephritic

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Differential Diagnosis Differential Diagnosis

Infectious
Renal Non Rule-in Rule-out

1. Pyelonephritis (+) hematuria (-) oliguria

(+) CVA tenderness (+) hypertension
(+) fever (+) edema
(+) abdominal pain
Infectious Non Infectious
2. Cystitis (+) hematuria (-) dysuria
(+) fever (-) urgency
(+) abdominal pain (-) frequency
(+) hypertension
(+) edema

Nephrotic Nephritic

Differential Diagnosis Differential Diagnosis

Nephrotic
Renal Non
Rule-in Rule-out

1.Nephrotic Syndrome (+) hematuria Can be rule out with c3

(+) edema and urinalysis
(+) abdominal tenderness
(+) hypertension

Non Infectious

Nephrotic Nephritic

Differential Diagnosis
Nephritic Course in the wards
Rule-in Rule-out
Throughout her hospital stay, the patient was placed on fluid limitation
1.IgA Nephropathy or (+) hematuria Can be rule out with
Berger disease (+) hypertension Urinalysis for the first 24 hours and on low salt, low fat, no pork, no beef diet.
(+) edema
(+) abdominal tenderness
Daily weight, blood pressure, urine input and output, and
2.Membranous (+) hypertension Can be rule out with C3
Glomerulopathy (+) edema
abdominal circumference were strictly monitored.
(+) hematuria
CBC, BUN, creatinine, ASO titers, C3 and KUB
3.Henoch-Schonlein (+) hypertension Can be rule out with ultrasound were requested.
Purpura Nephritis (+) edema creatinine and BUN
(+) previous streptococcal
infection Medications given were Nifedipine 5mg tab (0.6 mkD) maintained
(+) erythematous papular
rash at the lower extremities
every 8 hours then every 6 hours as needed if BP>120/90 (0.85
(+) abdominal tenderness mkD) and Furosemide 25mg IV every 12 hours (1.06 mkd)
(+) fever

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Complete Blood Count 07/04/17 Interpretation

Hemoglobin 96 Low

Course in the wards Hematocrit

WBC Count
0.29

10.5
Low

RBC Count 3.6 Low

Upon admission the following laboratory Differential Count

exams were revealed. Segmenters 0.59 High

Lymphocytes 0.30 Low

Eosinophils 0.06 High

Basophils 0.01

Monocytes 0.04

Platelet Count 256

Red Cell Indices

MCV 82.6

MCH 26. 9 Low

MCHC 326

RDW 12.6

KUB result
BUN, Creatinine, C3 and ASO
Both kidneys have homogenous parenchymal echogenicity.
titers
Right kidney measures 8.0x3.6cm
(normal length for age = 6.32 to 8.12cm) with parenchymal thickness of 0.7cm
07/04/2017 Interpretation
While the left kidney measures 8.5cmx4.3cm (normal length for
BUN (Blood Urea 5.2 (3.0 - 9.2) mmol/L Normal age = 6.72 to 8.56cm) with parenchymal thickness of 0.9cm .
Nitrogen) No caliectasia or renal lithiasis seen.
Creatinine 47.5 (53-97) umol/L Low
Urinary bladder is moderately filled with smooth, non thickened walls and no abnormal
ASO titers 400 (<200) IU/ml High
intravesical echoes seen, the total amount of urine in bladder is approximately 500cc,
C3 195 (1032 - 1495) mg/dL Low
which was reduced to 1.6cc on post void scan.

IMPRESSION: UNREMARKABLE KIDNEYS AND URINARY BLADDER

Urinalysis Course in the wards

Urinalysis 07/05/2017 Day 1
Color Yellow
Character Cloudy
On the 1st hospital day, the patient was active and there was noted decrease on
Specific Gravity 1.020 facial swelling and disappearance of periorbital edema.

Ph 6.0
Wt: 23Kg, Abdominal Circumference: 53cms, BP: 130/100,
Albumin +1
Intake: 520ml Output: 950ml (Urine Output 1.72 cc/kg/hr)
Sugar Negative
WBC 30-35/HPF Medications were continued and Furosemide IV was shifted to 20mg/tab PO 1 tab every
12 hours (0.87 mkd). Fluid limitation was discontinued
RBC 40-45.HPF
Bacteria +1 Repeat urinalysis was done
Mucus Threads +3
Casts: White Cell (Plus) 1-2/LPF

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Urinalysis Course in the wards

Urinalysis 07/05/2017 07/06/2017
Color Yellow Light Yellow
Day 2
Character Cloudy Slightly Cloudy
Specific Gravity 1.020 1.015 On the 2nd hospital day, medications such as Nifedipine was
Ph 6.0 6.0 revised to 5mg every 6 hours as needed if BP>120/80 (1.09 mkD)
and Furosemide was continued as ordered (1.09 mkD).
Albumin +1 Negative
Sugar Negative Negative Wt: 18.3Kg, Abdominal Circumference: 50cms, BP: 120/80,
Intake: 570ml Output: 600ml (Urine Output 1.37 cc/kg/hr)
WBC 30-35/HPF 1-2/HPF
RBC 40-45/HPF 40-45/HPF There was no noted facial swelling, periorbital edema, abdominal
Bacteria +1 FEW distention, and CVA tenderness. The patient had stable vital signs
hence, advised for discharge.
Mucus Threads +3
Casts: White Cell 1-2/LPF
(Plus)

Differential Diagnosis Differential Diagnosis

Nephrotic Syndrome
Renal Non
Rule-in Rule-out

1.Nephrotic Syndrome (+) hematuria Rule out with low C3

(+) edema (-) massive proteinuria
(+) abdominal tenderness
(+) hypertension

Non Infectious

Nephritic

Differential Diagnosis PRIMARY DIAGNOSIS

Nephritic POST STREPTOCOCCAL
GLOMERULONEPHRITIS Bases
Rule-in Rule-out History Physical Examination Laboratory Exams

1.IgA Nephropathy or (+) hematuria (-) proteinuria 6 year old Hypertension - BP=130/100 High ASO titer 400
Berger disease (+) hypertension (-) History of viral sydrome Abdominal tenderness mmHg
(+) edema (+) low C3 Sore throat and dysphagia Tachypnea - RR=36cpm Urinalysis:
(+) abdominal tenderness Fever Abdominal circumference: Increase WBC
Facial swelling 56.5cm Increase RBC
2.Membranous (+) hypertension Can be rule out with low C3 Periorbital edema (+) Erythematous Papular
Glomerulopathy (+) edema Vomiting Rash Low C3 - 195
(+) Facial swelling
(+) Periorbital edema Unremarkable KUB
3.Henoch-Schonlein (+) hypertension Rule out with low creatinine (+) Hypertrophic tonsils (Grade
Purpura Nephritis (+) edema and normal BUN II)
(+) previous streptococcal (+) Submandibular and anterior
infection cervical lymphadenopathy
(+) erythematous papular (+) Globular abdomen
rash at the lower extremities (+) Direct tenderness on the
(+) abdominal tenderness Left lower abdomen
(+) fever (+) Bilateral CVA tenderness

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Acute Post-Streptococcal
Glomerulonephritis

• Post-infectious sequelae of Nephritogenic

strains of Group A β-Hemolytic Strep infection
• Streptococcal pharyngitis (M-12)
DISCUSSION • Streptococcal pyoderma (M-49)
• Characterized by an Acute Nephritic Syndrome
• Gross hematuria/ “Tea-colored” urine
• Hypertension
• Edema
• Renal Insufficiency

Acute Nephritic Syndrome in the Acute Nephritic Syndrome in the

Patient Patient

• Edema
• facial swelling and periorbital edema noted starting 3 days PTC • APSGN is one of the most common causes
• Hypertension of gross hematuria in children

• PE: blood pressure was 130/100 mmHg • Evidence of prior streptococcal infection
• ASO titer: 400 IU/ml
• “Tea-colored” urine • History
• UA upon admission: RBC: 35-40/HPF

Initial Streptococcal Infection Initial Streptococcal Infection

• Sore throat and dysphagia starting 5 days

prior to consult
• Progressed to having associated fever, non-
productive cough, and then colds • Development of acute nephritic syndrome
• PE: non-hyperemic, hypertrophic (Grade II) Palatine • Strep Pharyngitis - 1-2 wks
Tonsils, non-exudative; multiple hypopigmented • Pyoderma - 2-6 wks
lesions on the trunk and extremities

• Probable initial infection: Acute

Tonsillopharyngitis, non-exudative

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Pathogenesis
Strep Pharyngitis

Anti-streptococcal
Ab formation (M12)

in situ immune
complex formation

formation of Ab-Ag
deposits on the
epithelial side of the
GBM

complement
activation

Subepithelial deposits
“Humps”

Pathogenesis
Glomerular
infiltration by
inflammatory
cells

decrease basement
membrane permeability

reduced glomerular
surface area

reduced GFR

salt and water edema/congestion

retention

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Clinical Course

Progression

• Prior infection: Streptococcal Pharyngitis

• Acute nephritic syndrome developed 2 days
after onset of symptoms

Clinical Course
Complications

• Acute Renal Failure

• Hypertension
• Hypertensive Encephalopathy
• Edema/Fluid Retention
• Congestion/Heart Failure

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Clinical Manifestations of the Clinical Manifestations in the

Patient Patient

• Hematuria
• Edema • Edema
• facial swelling and periorbital edema noted starting 3 days PTC
• Hypertension • Hypertension
• Cerebral Symptoms • PE: blood pressure was 130/100 mmHg
• Oligoanuria • “Tea-colored” urine
• Cardiopulmonary • UA upon admission: RBC: 35-40/HPF
• Anemia
• Renal insufficiency

Management

• Best opportunity for intervention is during

Management Oliguric Phase
• Principle of treatment: shorten the oliguric
phase and minimize complications

Diagnostic
Diagnostic

• Anti-Streptolysin O Titer
• Urinalysis • to confirm previous strep infection
• to monitor hematuria, proteinuria, pyuria • KUB ultrasound
• CBC with Platelet count • to evaluate for GUT structure
• to evaluate for dilutional anemia or systemic infection
• C3
• Serum BUN and Serum Creatinine • to evaluate for hypocomplementenemia
• to evaluate for azotemia

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Complete Blood Count 07/04/17 Interpretation

Hemoglobin 96 Low

Hematocrit 0.29 Low

Diagnostics in the Patient WBC Count 10.5

RBC Count 3.6 Low

Differential Count

Segmenters 0.59 High

Lymphocytes 0.30 Low

Eosinophils 0.06 High

Basophils 0.01
• CBC, Urinalysis, BUN, creatinine, ASO titers, C3 and KUB
Monocytes 0.04
ultrasound were requested upon consult
• Urinalysis was repeated on day 1 hospital admisison Platelet Count 256

Red Cell Indices

MCV 82.6

MCH 26. 9 Low

MCHC 326

RDW 12.6

KUB result
BUN, Creatinine, C3 and ASO
Both kidneys have homogenous parenchymal echogenicity.
titers
Right kidney measures 8.0x3.6cm
(normal length for age = 6.32 to 8.12cm) with parenchymal thickness of 0.7cm
07/04/2017 Interpretation
While the left kidney measures 8.5cmx4.3cm (normal length for
BUN (Blood Urea Nitrogen) 5.2 mmol/L Normal age = 6.72 to 8.56cm) with parenchymal thickness of 0.9cm .
No caliectasia or renal lithiasis seen.
Creatinine 47.5 umol/L Low

ASO titers 400 IU/ml High

Urinary bladder is moderately filled with smooth, non thickened walls and no abnormal
C3 195 Low intravesical echoes seen, the total amount of urine in bladder is approximately 500cc,
which was reduced to 1.6cc on post void scan.

IMPRESSION: UNREMARKABLE KIDNEYS AND URINARY BLADDER

Urinalysis
Urinalysis 07/05/2017 07/06/2017
Color Yellow Light Yellow Therapeutic
Character Cloudy Slightly Cloudy
Specific Gravity 1.020 1.015
• Antibiotic Therapy to limit spread of
Ph 6.0 6.0 nephritogenic organisms
Albumin +1 Negative • Penicillin for 10 days
Sugar Negative Negative • Diuretics for edema
WBC 30-35/HPF 1-2/HPF • Furosemide IV
RBC 40-45/HPF 40-45/HPF • Antihypertensives
Bacteria +1 FEW
• ACE inhibitors
• Calcium Channel Blockers
Mucus Threads +3
• Vasodilators
Casts: White Cell 1-2/LPF
(Plus)

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Therapeutics in the Patient Supportive

• Daily weight monitoring

• No antibiotics were given to the patient • Intake and output monitoring
• Antihypertensive: Nifedipine 5mg Q6 PRN if BP >120/90 • Diet restrictions
• Diuretic: Furosemide 25mg IV Q12 • Fluid limitation
• Strict Blood pressure monitoring

Prognosis Resolution

• Complete recovery in 95% of children • Gross Hematuria: 2-3 weeks

• Mortality in the acute stage is limited with appropriate
management of the acute effects of renal insufficiency
• Serum complement: 6-8 weeks
• Proteinuria: 3-6 months
• Microscopic Hematuria - 6-12 months
• Histologic resolution - 1-2 years

CRITICAL
APPRAISAL

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CLINICAL QUESTION

Among patients with Acute Post

Streptococcal Glomerulonephritis (P), will
Calcium Channel Blockers (E) demonstrate a
better therapeutic outcome (O) for
hypertension compared to ACE inhibitors?

EVALUATING DIRECTNESS APPRAISING VALIDITY

Clinical Question Journal Article 1. Were the patients randomly
P: Patients with acute post P: Patients with acute assigned to treatment groups?
streptococcal glomerulonephritis post streptococcal
glomerulonephritis with
some inclusion and
exclusion criteria

E: Calcium channel blockers and ACE E: Calcium channel

inhibitors blockers and ACE
inhibitors

O: Resolution of hypertension O: Resolution of

hypertension

APPRAISING VALIDITY APPRAISING VALIDITY

3. Were baseline characteristics similar at
2. Was allocation concealed?
the start of the trial?

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APPRAISING VALIDITY APPRAISING VALIDITY

3. Were baseline characteristics similar at
4. Were patients blinded to treatment assignment?
the start of the trial?

APPRAISING VALIDITY APPRAISING VALIDITY

5. Were caregivers blinded to 6. Were study personnel blinded to
treatment assignment? treatment assignment?

APPRAISING VALIDITY APPRAISING VALIDITY

7. Were all patients analyzed under the groups to
8. Was follow-up rate adequate?
which they were originally randomized?

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INTERPRETING RESULTS INTERPRETING RESULTS

1. How large was the effect of the treatment? 1. How large was the effect of the treatment?

INTERPRETING RESULTS INTERPRETING RESULTS

1. How large was the effect of the treatment? 2. How precise was the estimate of the
treatment effect?

ASSESSING ASSESSING
APPLICABILITY APPLICABILITY
1. Are there biologic issues that may
affect applicability of treatment? 2. Are there socio-economic issues
affecting applicability of treatment?
There are no socio-economic issues that may affect the
applicability of the treatment since the antibiotic regimen
used in the study is widely available here in the Philippines.
From mims.com:
•Nifedipine tab/cap: 100’s
•Captopril tab: 100’s

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INDIVIDUALIZING THE
RESULTS
Are the results beneficial to your patients worth the
harm and costs?

The desired effects upon the administration of Calcium

channel blockers and ACE inhibitors are similar but the
difference of the earliest time it could reduce the high blood
pressure and the duration of therapy may be beneficial for
the patients.

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DE LA SALLE UNIVERSITY MEDICAL CENTER Objectives

Department of Orthopaedics

CASE At the end of this session, the clinical clerks

should be able to determine:
MANAGEMENT ● Salient features
CONFERENCE ●
●
Clinical picture
Diagnostics
December 15, 2017 ● Management

of open fractures.

General Data
Chief Complaint
• C.B.
• 15 year old
• Male Wound, Right foot
• Catholic
• Filipino
• Dasmariñas, Cavite

History of Present Illness
2 hours PTA:
Two hours
PTA
• He was using an electric grass cutter
• The blade hit his right foot
• Blade was manually removed
• Consulted at a local clinic
• Wound care done
• Consulted at our institution

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Past Medical History Past Medical History

• (-) Allergies to food and drugs • (-) History hospitalization
• (-) Asthma • (-) History of accidents
• (-) Hypertension
• (-) History of any operations
• (-) Diabetes
• (-) Tuberculosis
• (-) Respiratory diseases
• (-) Heart disease
• (-) Kidney diseases.

Family History Family History

• Hypertension (Maternal) (-) Cardiovascular disease

• Diabetes Mellitus (Father and (-) Hematologic disease
Cousin) (-) Pulmonary disease
(-) Asthma
(-) Cancer

Review of Systems
SYSTEM
Personal and Social History General: (-) weakness, (-) loss of appetite, (-) fever, (-) weight loss, (-) easy
fatigability

•Works as a Grass cutter in the
orchard in a golf field club
• Non-smoker and non-alcoholic beverage drinker
•Denies of any use of illicit drugs
Integument: (-) wound, (-) rashes, (-) erythema, (-) pallor, (-) clubbing of nails, (-)
hyperpigmentation, (-) hypopigmentation, (-) mass
Head and Neck: (-) stiffness, (-) dizziness, (-) headache, (-) swelling, (-) distention of
veins, (-) mass
Eyes: (-) pain, (-) inecteric sclera, (-) redness, (-) corrective lenses, (-)

•Lives with mother and father with 7 discharge, (-) blurring of vision

other siblings in a kubo style house Ears: (-) otalgia, (-) vertigo, (-) tinnitus, (-) hearing loss

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Review of Systems Review of Systems

Nose and Sinuses: (-) discharge, (-) epistaxis, (-) obstruction
Vascular: (-) varicose veins, (-) claudication, (-) ulcers
Mouth and Throat: (-) toothache, (-) tongue fasciculation, (-) hoarseness, (-) sore
Hematologic: (-) easy bruising, (-) easy bleeding, (-) pallor
throat, (-) dysphagia, (-) ulcers
Respiratory: (-) cough, (-) bradypnea, (-) dyspnea, (-) pleuritic chest pain, (-)
Endocrine: (-) polyuria, (-) heat tolerance, (-) polyphagia, (-)
hemoptysis, (-) phlegm, (-) tachypnea polydysplasia, (-) diaphoresis
Cardiovascular: (-) angina, (-) dyspnea, (-) palpitations MSS/Extremitie (-) joint pains, (-) edema
s:
GIT: (-) anorexia, (-) abdominal distension, (-) hematemesis, (-) nausea, (-) Nervous (-) seizures, (-) syncope, (-) tremors, (-) irritability
abdominal pain, (-) hematochezia, (-) vomiting, (-) constipation, (-) System:
retching, (-) diarrhea, (-) melena
GUT: (-) frequency, (-) nocturia, (-) nausea, (-) dysuria, (-) polyuria, (-) flank
Autonomic (-) fetal incontinence, (-) urinary incontinence
pains, (-) oliguria (-) palpable mass Deficiency:

General Survey
• Came in ambulating
• Awake, conscious, coherent
Physical Examination • Not in cardiorespiratory distress
• Looks his chronological age of 15 years old

Regional Examination
Vital Signs
SYSTEMS Findings
• BP =
SHEENT (-) pallor, jaundice; anicteric sclerae, pink
100/60mmHg • Wt = 30 kg
palpebral conjunctiva; (-) CLADs
• HR = 84bpm • Ht = 131 cm Chest/Lungs Clear breath sounds, symmetrical chest
• BMI = 17.48 expansion
• PR = 84bpm kg/m2 Heart Normal rate and regular rhythm, (-) murmur
• RR = 18cpm Abdomen Soft, flat, nontender
• T = 36.90C
3
 6/9/2018

Gross Pictures Neurologic

• Mental Status Examination

Alert, mobile, active, well-groomed, dressed
appropriately according to age and occasion
He did not experience illusions, delusions, paranoia, or
any auditory or visual hallucinations

Neurologic
• Mental Status Examination
He is awake and conscious and is
able to interact with examiner and
recognize faces and respond to
eyes IV, VI aligned, (-) nystagmus As observed
touch.
CN FINDINGS
(+) Not assessed
(+) (+) Direct and Consensual light reflex
III, EOM intact, symmetrical palpebral fissure,
(+) Good masseter contraction,
intact sensation on light touch

CN FINDINGS
VII Good facial movements and tone, CN FINDINGS
(-) Facial asymmetry; the patient (-) Atrophy of SCM and
was able to shut his eyes tightly
XI Trapezius
muscle
VIII Intact gross hearing Tongue in midline
XII
IX, X Symmetrical palate, uvula is in the (-) Atrophy (-)
fasciculations, (-)
midline, no hoarseness of voice asymmetry
4
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Motor System
Cerebellar Exam
Not done. Not done
Reflexes Meningeals
All of the reflexes are intact. The tests for passive neck flexion, Kernig’s,
There is no primitive reflex noted. and
Brudzinski are all negative.
Sensory Testing
100% on both upper and lower extremities

Management at the ER
Primary Impression •History and Physical Examination
•Wound dressing
Incised wound, Right Foot; R/O •Complete Blood Count
At the
fracture ER

Laboratory Results Laboratory Results

Complete Blood Results Reference Values Complete Results Reference
Count Blood Count Values
Segmenters 0.84 H 0.45 - 0.55
Hemoblogin 150 H 115-148 g/L
Lymphocytes 0.13 L 0.38 – 0.45
Hematocrit 0.45 H 0.38-0.44 Eosinophils 0.01 L 0.02 – 0.05
Basophils 0.00 0.00 – 0.01
WBC count 11.0 4.0 - 11.0 x
Monocytes 0.02 L 0.03 – 0.06
10^9/L
Platelet Count 298 150 – 400 x 10^9?L
RBC count 5.4 3.8 - 5.4 x 10^9/L

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Laboratory Results

Red Cell Indices Results Reference Values

MCV 82.2 80 - 96 fl
MCH 27.6 27 – 31 pg
MCHC 336 320 – 360 g/L
RDW 13.5 11 – 12 %
BLOOD TYPING “B” Rh Positive
ABO RH

Management at the ER FINAL DIAGNOSIS

(+) Therapeutics:
Ig Tetanus and Tetanus toxoid via IM
Cefuroxime 1.5 g Q8 via IV Fracture Open Type IIIA,
Gentamycin 80mg Q12 via IV At the
Undisplaced, 1st metatarsal, Right
ER
Penicillin G 4 million units Q8 via IV
•Advised for admission and
subsequent wound
debridement and suturing

OPEN FRACTURES
Discussion

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Definition Diagnostic Clues

(+) Soft tissue injury with cortical break (+) Exposed bones
(+) Presence of fat droplets
(+) Communication of the bone or fracture (+) Radiolucent on x-ray
hematoma with the outside environment through
a break in the skin an underlying soft tissue

Gustilo Classification

Gustilo Classification of Open Fracture

Gustilo Classification of Open Fracture
TYPE I
Periosteal Stripping No
TYPE I Skin Coverage Local Coverage
Wound < 1cm Neurovascular Injury Normal
Energy Low energy Antibiotics 1st generation cephalosporins for 24 hours after
Soft Tissue Minimal Other considerations closure
Fluoroquinolones (Can be used for fresh water
Contamination Clean wounds or salt water wounds and if allergic to
Fracture Pattern Simple fracture pattern with minimal cephalosporins or clindamycin)
Doxycycline and Ceftazidime (can be used for salt
comminution
water wounds)

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Type I Gustilo Classification of Open Fracture

TYPE II
Wound 1 – 10 cm
Energy Moderate Energy
Soft Tissue Moderate
Contamination Moderate
Fracture Pattern Moderate comminution

Gustilo Classification of Open Fracture

Type II
TYPE II
Periosteal Stripping No

Skin Coverage Local Coverage

Neurovascular Injury Normal

Antibiotics 1st generation cephalosporins for 24 hours after

Other considerations closure
Flouroquinolones (Can be used for fresh water wounds
or salt water wounds and if allergic to cephalosporins
or clindamycin)
Doxycycline and Ceftazidime (can be used for salt
water wounds)

GUSTILO-ANDERSON TYPE III TYPE IIIA

(+) Adequate periosteal coverage of the fracture
(+) Open bone despite the extensive soft-tissue laceration or
segmental damage
fracture wound
(+) High level of contamination
with extensive
soft tissue injury
(>10cm)

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TYPE IIIA TYPE IIIB

(+) Antibiotic Therapy Extensive soft-
tissue loss,
First generation Cephalosporins + Aminoglycosides moderate
periosteal
E.g. Cefazolin IV + Gentamicin IV stripping and
bone damage
(+) Tetanus Prophylaxis – Tetanus Toxoid and Ig Tet
Massive
contamination
(+) Definitive Treatment
Need further
Open reduction, External Fixation soft-tissue
coverage
Primary closure procedure

TYPE IIIB TYPE IIIC

(+) ANTIBIOTIC THERAPY (+) -
First Generation Cephalosporin + Aminoglycoside +
Associated with
an arterial injury
Penicillin E.g Cefazolin IV + Gentamicin IV + Penicillin G IV requiring repair,
irrespective of
(+) TETANUS PROPHYLAXIS – Tetanus Toxoid and Ig Tet IM
degree of soft-
(+) DEFINITIVE TREATMENT tissue injury
Viable – Open Reduction, External Fixation; Free or
High Level of
Rotational Flap Repair
Contamination
Non-viable – Limb amputation

TYPE IIIC
• ANTIBIOTIC THERAPY
First Generation Cephalosporin + Aminoglycoside + Penicillin E.g

Cefazolin IV + Gentamicin IV + Penicillin G IV

• TETANUS PROPHYLAXIS – Tetanus Toxoid and Ig Tet IM

• DEFINITIVE TREATMENT Special Types

Viable – Open Reduction, External Fixation; Vacuum
assisted closure or Flaps & Vascular Injury Repair

Non-viable – Limb amputation

9

Shotgun wounds
• wounding capability of
a bullet directly related
to its kinetic energy
• damage caused by:
• passage of missile
• secondary shock wave
• cavitation
High-velocity Shotgun wounds
• muzzle velocity >600
meters per second or
>2,000 feet per second
• military (assault)
and hunting rifles
Segmental Fractures
• 2 fracture lines that together
isolate a segment of a bone
• high energy trauma with damage
to surrounding soft tissue
• Increased morbidity and long
term complications (delayed
union, non-union, compartment
syndrome or infection)
6/9/2018
Shotgun wounds
• exponential increase in
injury with increasing
velocity and efficient
energy transfer
• fractures may be caused
even without direct impact
High-velocity Shotgun wounds
• wounds comparable to
Gustillo-Anderson Type
III regardless of size
• high risk of infection
secondary to wide zone
of injury and devitalized
tissue
Farmyard Injuries and Fractures Occurring
in Highly Contaminated Environment
• Type III fractures with
contamination from gram-negative
organisms and/or anaerobes
• Primary closure: contraindicated.
Debridement: <6 hours for infection prevention
10

MANAGEMENT
LOCAL ANTIBIOTIC
• ANTIBIOTIC BEAD POUCH
Principle in Managing Open Fractures
Goals
• prevention of infection
• achievement of bony union
• restoration of function
6/9/2018
Irrigation Principle in Type III Open Fracture
• 9 L normal saline with liquid castile soap additive.
• Highly contaminated wounds may benefit from
antibiotic in the irrigation solution.
Indications for Amputation vs. Limb Salvage
• Non-viable limb
• Non viability even after revascularization
• In a presence of severely debilitating or chronic diseases
• Demand several operative procedures
• Mass casualty situation
• Severe multi system injuries
Principles in Management of Open Fractures
• Treat all open fractures as emergency
• Treat first all life threatening conditions
• Immediate wound debridement
• Appropriate antibiotics
• Stabilization
• Early soft tissue coverage
• Identify and treat complications
• Early rehabilitation
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Day 1
Subjective Objective Assessment Plan
(+) pain on affected Stable Vital Signs Open Fracture Type Patient is for
foot IIIA, Undisplaced, discharge:
Course in the wards 1st metatarsal right;
S/P Wound
Home medications:
1. Cefuroxime (50
debridement and mg) - 1 capsule 3
suturing times a day for 7
days
2. Ibuprofen (40
mg) - 1 capsule 3
times a day for 7
days

Day One Drug Index Cefuroxime

• Cefuroxime • Spectrum of Activity
• 50 mg 1 capsule 3 times a day for 7 days • E. coli, Klebsiella, Proteus, H. Influenzae,
• Ibuprofen Moraxella catarhrhalis
• 40 mg 1 capsule 3 times a day for 7 days • Increase activity against Gram Negative organism

Cefuroxime Cefuroxime

• Mechanism of Action • Clinical Use

Cell wall synthesis inhibitors Soft tissue and bone infections
Meningitis
UTI
Sinisusitis

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Ibuprofen Ibuprofen

• Mechanism of Action • Clinical Use

Selective inhibitor of COX Pain management
Fever
Anti inflammatory

References
• Cross, W. & Swiontkowski, M. (2008) Treatment principles in the
management of open fractures. Retrieved December 11, 2017 from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740354/
• Murphy, A. & Hacking, C. Gustilo Anderson classification. Retrieved
December 11, 2017 from https://radiopaedia.org/articles/gustilo-
anderson-classification
• Canon, J. & Rasmusen, T. (2017) Severe extremity injury in the adult patient.
Retrieved December 11, 2017 from https://www.uptodate.com/contents/severe-
extremity-injury-in-the-adult-
patient?source=machineLearning&search=gustilo&selectedTitle=1~3&secti
onRank=1&anchor=H151204170#H151204170
 6/9/2018

Objectives
● To discuss the following:
CLINICAL MANAGEMENT ● a.) clinical
● b.) psychosocial
CONFERENCE ● c.) health system issues of the case (identify missed opportunities
for care and suggest ways to improve care processes

ENT JANUARY 1-15 ROTATORS
BANTILAN | CANUTO | DELA CRUZ | FORTUNO | GABORNO | IGNACIO |
LU| MALIMBAN | NEYRA | QUINTO | SUPILLO
JANUARY 10, 2018
● 1. Discuss and correlate clinical presentation with pathophysiologic
mechanism and propose individualized diagnostic and therapeutic
interventions based on basic and clinical sciences
● 2. Discuss the patient’s ability to comply with the proposed
treatment and explore barriers to such compliance
● 3. Discuss the health system issues that influence the quality and safety
of care of the patient.

General Data
• Alice
• 25 year old female
• Chief Complaint:
CLINICAL APPROACH Severe headache

Scenario
History of Present Illness
• Patient arrived early morning
• 6 days prior to consult • Did not know what exactly what to do or who to see
Severe headache located on the forehead (first time in hospital)
• Everybody looked like they were in a hurry and they did not look
Colds, 6 day duration very friendly. Some of them looked as frightened as I was.

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 6/9/2018

POINTS TO CONSIDER PRIMARY IMPRESSION

• Complete History and Physical Examination - “Bread
and Butter” of Medicine
• ACUTE RHINOSINUSITIS
Onset, character, intensity, duration, and interval • BASES FOR DIAGNOSIS:
Precipitating, relieving and aggravating factors 6 day history of Colds
Past Medical History Severe headache located on the forehead
Family History
Personal Social History

DIFFERENTIAL DIAGNOSES
Rule In Rule Out
Influenza (+) Headache on the forehead Body malaise, joint pains and fever
(+) Colds usually accompanies the headache Rule In Rule Out

Migraine (+) Headache on the forehead Duration of headache (6 days) Brain Cancer (+) Headache on the forehead Patient’s Age
Associated with colds (+) Family history of brain cancer Cannot be totally ruled out

Cannot be completely ruled out

Tension Headache
(+) Headache on the forehead
until history and physical exam
proves otherwise
Character of headache should be
noted to be worsening as the day
goes on
Associated with other symptoms

Cannot be completely ruled out

until history and physical exam
proves otherwise

CASE DISCUSSION PATHOPHYSIOLOGY

Acute Rhinosinusitis is the inflammation of the nose Closed Ostium

and paranasal sinuses less than 4 weeks in duration Further blockage

Mucosal congestion or
anatomic obstructio

• Etiology
VIRAL
Bacterial infection Secretion Stagnate
BACTERIAL

Retained secretions Secretions thickens

creates culture medium

Mucosal gas
for bacterial growth in
closed actiivity metabolism changes

Cillia and epithelium are

damaged

2
 6/9/2018

DIAGNOSTICS THERAPEUTICS
• PHYSICAL EXAMINATION NON-PHARMACOLOGICAL
• ENDOSCOPIC EVALUATION • Bed rest
• IMAGING STUDIES • Increase oral fluid intake
X-RAY OF THE PARANASAL SINUSES
CT SCAN
MRI PHARMACOLOGICAL
• LABORATORY STUDIES (+) NaCl Nasal Spray, 2-3 sprays on each nostril TID x 7days
CBC (+) Phenylpropanolamine HCl + Chlorphenamine
Maleate + Paracetamol Tablet, 1 tablet Q6 for 5 days

PROBLEMS CONTRIBUTING TO THE DISEASE PROCESS

Poverty
Unemployment
(+) Other sickness in the family
PSYCHOSOCIAL APPROACH

Poor patient compliance with medications

PSYCHOSOCIAL APPROACH Responsibilities of the Physician

• Explore for patient’s understanding of the (+) Explore routinely level of understanding of the
following issues: patient & assess her fears based on her understanding of the
Etiology illness
(+) With appropriate label of illness, acknowledgement &
Pathophysiology conflict the patient may be experiencing regarding her condition
Trajectory and outcome of her illness (+) Explore several aspects of pre-diagnostic phase of patient &
Appropriate treatment family

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 6/9/2018

Health System Issues

• Proper direction to clinical and out-patient departments for all
patients who come in the hospital
• Increase hospital workforce
HEALTH SYSTEM ISSUES • Proper triage of patients
• Utilizing both holistic and practical approach in patient management
• Adequate and thorough explanation of diagnostics being requested
• Complete disclosure of information regarding the patients diagnosis,
management, and current medical status

Department of Internal Medicine

Case Management

General Objectives
Conference: “Go on! Leave me
breathless!”
FRANCIA · LU · MALIMBAN · RAKSHAM
Specific Objectives
General Data
To gather pertinent information through complete
history and thorough physical examination.
To formulate all possible differential
diagnoses based on history and PE.
To discuss a complete plan of management with
diagnostics, therapeutics and supportive
regimen for the patient.
Chief Complaint
History of Present Illness
“Cough”
6/9/2018
At the end of this 1 hour session, the clinical
clerks should be able to recognize, clinically
diagnose and manage a patient with pleural
effusion 100% of the time, at all possible
settings and circumstances.
MC
55 year old, Female
Married, Filipino, Roman Catholic
Born on November 7, 1962 at Negros
Oriental Currently residing at Taguig City
Admitted for the first time at DLSUMC on Feb
15, 2018 at 1:30 PM
7 weeks PTA
(+) Productive cough with whitish phlegm and clear
nasal discharge
(+) difficulty of breathing and easy fatigability
Consult was done
Rx: Dextromethorphan + Phenylephrine
+ Paracetamol (Tuseran)
1
 6/9/2018

History of Present Illness History of Present Illness

Interim One week PTA

Persistence of symptoms Persistence of symptoms
Consult with another AP; Dx: Allergic cough (+) chest heaviness aggravated by
Rx: Montelukast 10mg OD bending forward.
Consulted another AP
CXR and CBC was advised.

History of Present Illness CXR

2/12/18

One day PTA

CXR: Homogenous based opacity in the
left hemithorax
Persistence of symptoms
ER consult and subsequent admission

Past Medical History Family History

Hyperthyroidism (2017), Rx: Methimazole (+) HPN, DM, Prostate Ca – paternal side
Cholelithiasis (2017) – no intervention yet (+) PTB exposure – husband ongoing 6
Allergies to dust and smoke months treatment; continuation phase

(-) Asthma, DM, HPN, Heart Disease, PTB, (-) Asthma, allergies, heart disease
cancer, previous surgeries

2
 6/9/2018

Personal and Social History Menstrual History

(-) Smoker (-) Alcoholic Beverage Drinker (-) Illicit Drug use M: 13

(+) Husband is smoker – 2 pack years I: Regular

Administrative assistant, receives chemical D: 3-5 days

samples including pesticides A: 3-4 moderately soaked pads
4 household members: patient, husband and 2 sons. S: (-) dysmenorrhea, intermenstrual bleeding
Concrete house with poor ventilation and sunlight entry
Menopausal for 5 years (50 years old)

Obstetric History Review of Systems

OB Score of G5P5 (5005)
All births via VSD with no complications noted.
Gynecologic History
No vaginal discharge, pruritus, post-coital bleed,
dyspareunia No breast lumpiness, tenderness
One month use of unrecalled OCP, no adverse effects noted
General: (-) weakness (-)weight loss (-)chills (-) loss of appetite
SHEENT: (-)cyanosis (-)jaundice (-) edema (-)masses (-)stiffness of
neck (-)pain (-)discharge (-) BOV (-) nasal obstruction (-) epistaxis (-
)dysphagia (-)sore throat
Cardiovascular: (-) chest pain (-) palpitations (-) orthopnea
GIT: (-)abdominal pain (-)constipation/diarrhea (-)nausea/vomiting
GUT: (-)oliguria (-)dysuria (-) hematuria
Endocrine: (-)polyuria (-)polydipsia (-)heat and cold tolerance
Extremities: (-) joint pain (-) muscle pain (-)edema
Hematologic: (-) easy bruisability

General Survey and Vital Signs

Awake, conscious, coherent, oriented in three spheres
Fairly developed, fairly nourished, appears her age
In cardiorespiratory distress
PHYSICAL EXAMINATION BP:120/80
mmHg; T: 37.2 C
HR: 82
RR: 24 cpm,
O2 Sat: 94%,

3

SHEENT
Skin: The skin is moist, smooth texture, with good capillary
refill, no cyanosis, pallor, jaundice or rash, noted.
Head: Head is normocephalic and symmetrical with gray hair
evenly distributed.
Eyes: Pupils 3mm equal and briskly reactive to light, EOMs full and
equal at all 6 cardinal directions of gaze, no excessive lacrimation.
Ears: No lesion, mass, or deformity of Pinna or peri-auricular
area, external ear canal opening patent.
Nose: Patent; no septal deviations. (-) discharge
Throat: (-) cervical lymphadenopathies (-) thyroid gland not palpable
(+) trachea midline (-) neck vein distention
Heart
Inspection: (-) precordial bulge; PMI at the 5th ICS LMCL
Palpation: Apex beat at the 5th ICS LMCL, no heaves no
thrills
Ausculatation: Normal rate at 82 bpm, regular rhythm,
S1>S2 at the apex, S1<S2 at the base, no S3 or S4, no
murmurs.
Extremities
(-) Swelling (-) Redness
(-) Limitation of ROM
(-) tenderness (-) edema
Full and equal peripheral pulses
6/9/2018
Chest and Lungs
Inspection: (-) Chest deformities (-) retractions (-) use of accessory muscles; AP:T=1:2
Palpation: (+) Asymmetric chest expansion, slight lag on the left
(+)decreased tactile fremitus on the left lower lung
fields (-) mass (-) tenderness
Percussion: (+) Dullness on the left lower lung fields
Auscultation: (+) absent breath sounds on the left lower lung
fields (-) crackles (-) wheezes (-) rhonchi
Breast Exam: (-) Dimpling (-) Mass (-) Tenderness (-) Nipple Discharge
Abdomen
Inspection: Flat (-) scars (-) visible veins or pulsations
Auscultation: normoactive bowel sounds at 9/min, (-) bruit
Percussion: Tympanitic in all quadrants
Palpation: (-) tenderness (-) mass (-) organomegaly
Neurologic
No Cranial nerve deficits
No nystagmus, pronator drift
No nuchal rigidity, No Babinski Reflex
Motor: 5/5 all extremities
Sensory: 100% all extremities
Reflexes: ++
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 6/9/2018

History Physical Examination

55 years old female In cardiorespiratory distress

(+) Cough RR: 24cpm
(+) Difficulty of breathing O2sat 94%
(+) Easy fatigability (+) Asymmetric chest expansion,
(+) Chest heaviness aggravated by slight lag on the left
Salient Features bending forward (+) decrease tactile fremitus on the
(+) CXR – Homogenous opacity in the left lower lung fields
left hemithorax (+) dullness upon percussion on left
(+) PTB exposure lower lung fields
(+) History of cancer in the paternal (+) absent of breath sounds on the
side left lower lung fields
(+) husband is smoker – 2pack years

Primary Impression:
Tuberculous Pleural Effusion, Left;
Hyperthyroidism in Euthyroid DIFFERENTIAL DIAGNOSES
State; Cholelithiasis

Differential Diagnosis
Transudative Pleural Effusion Exudative Pleural Effusion

1. CHF 1. Neoplastic Diseases

2. Cirrhosis 2. Infections diseases COURSE IN THE ER

(Bacterial, TB, Fungal, Viral,
Parasitic)
3. Nephrotic Syndrome 3. Pulmonary Embolism

4. Myxedema 4. GI disease (esophageal

perforation, pancreatic
disease)

5
 6/9/2018

Day 0 (2/14/18) EMERGENCY ROOM

CXR AP
Problem Findings Assessment Plan 2/15/18
PRODUCTIVE VS: Tuberculous For admission
COUGH BP – 120/80 mmHg Pleural Lateral Decubitus x-ray
DIFFICULTY PR – 82 bpm Effusion, Left Sputum GS/CS
OF RR – 22 cpm
CBC
BREATHING T – 37.2C Creatinine
EASY O2 – 94%
UNEQUAL BREATH SOUNDS Serum sodium and
FATIGABILITY
(R>L) potassium
CHEST PAIN
(-) ADVENTITIOUS BREATH
SOUNDS
CXR PA and Left Lat:
Pleural Effusion, Left

LEFT LAT Parameter 2/15/18

CBC
2/15/18
Hgb 133
Hct 41 (H)
WBC 9.6
RBC 4.7
Segmenters 0.6
Lymphocytes 0.33
Eosinophils 0.03
Basophils 0.01
Monocytes 0.03
Platelet Count 324
MCV 87.9
MCH 28.5
MCHC 324
RDW 11.8

COURSE IN THE WARDS

6
 6/9/2018

Day of Admission (2/15/18)

Problem Findings Assessment Plan
(1) UNEQUAL BREATH Pulmonary AMPICILLIN SULBACTAM
PRODUCTIVE SOUNDS (R>L) Tuberculosis vs (UNASYN) 1.5g IV every 6 Parameter 2/15/18
Blood Chemistry
COUGH (-) ADVENTITIOUS Community hours
Serum Creatinine 64.1 umol/L
BREATH SOUNDS Acquired Pneumonia Serum Sodium 141
Serum Potassium 4.0
DIFFICULTY OF VS: Tuberculous Pleural Oxygen support via nasal Protein Profile
BREATHING RR – 22 cpm Effusion, Left VS cannula at 1-2LPM Total Protein 65 g/L
O2- 94% Parapneumonic Albumin 39
PLEURAL TACTILE FREMITUS (R>L) effusion Referral to Surgery Globulin 26
EFFUSION DECREASED BREATH department for possible A/G Ratio 1.5
LDH 166
SOUNDS ON LEFT LUNG thoracentesis

Hospital Day 1 (2/16/18)

Problem Findings Assessment Plan Parameter 2/16/18
Pleural Fluid
PLEURAL 200cc Serosangiounous Tuberculous Pleural fluid specimen Gram Stain Squamous Epithelial Cells: Few
EFFUSION pleural fluid in indwelling Pleural Effusion, sent for Cell cytology, No microorganisms seen
catheter Left s/p quantitative/qualitative KOH/TMG (-) Spores and Hyphae
Ultrasound-guided analysis, GS/CS, AFB, and Lipid Profile
2/16/18 Thoracentesis Triglycerides 0.85
Prothrombin Time KOH study. Cholesterol 4.25
PT 15.4 H WOF: Desaturation, Ultra HDL 0.82 (L)
PT INR 1.11 dyspnea and chest pain Direct LDL 2.96
% ACTIVITY 81
Start Orphenadrine CLDL 0.3864
Partial Thromboplastin Time Citrate with Aspirin 1 tab Albumin 37
APTT 38.8 H FBS 90mg/dL
APTT RATIO 1.25 H TID

ULTRASOUND-GUIDED THORACENTESIS 2/16/18 Qualitative/Quantitative Analysis 2/16/18

MACROSCOPIC MICROSCOPIC:
Scans: at least 1274cc of slightly echogenic fluid in the left Fluid: Pleural Fluid WBC count: 2,160/mm3
hemithorax (with atelectasis of the adjacent lung segments) Segmenter: 4%
Color: Red
No abnormal fluid accumulation noted in the right hemithorax. Lymphochytes: 96%
Character: Cloudy
Approximately 200cc of serosanguinous fluid was initially RBC count: 28,800/mm3
drained from the left hemithorax. Total Volume: 150ml CHEMISTRY:
A residual fluid volume of about 574cc is seen on post- Specific Gravity: 1.010 Sugar: 4.69mmol/L (84.50mg/dL)
thoracentesis scan. pH: 9 Protein: 60g/L
LDH: 54U/L

7
 6/9/2018

Comparison of Pleural Fluid Analysis Comparison of Pleural Fluid Analysis

Comparison of Pleural Fluid Analysis

Light’s Criteria
Pleural fluid protein/serum protein >0.5
Pleural fluid LDH/serum LDH >0.6
Pleural fluid LDH more than two-thirds the normal upper
limit for serum

Light’s Criteria

Pleural fluid protein/serum protein

60/65 = 0.92 (>0.5 exudative pleural effusion)
Pleural fluid LDH/serum LDH
54/166 = 0.3 (>6.0 exudative pleural effusion)
Pleural fluid LDH more than 2/3 normal upper limit for
serum 0.24 (<2/3 of the upper limit 220 U/L)

Pleural Fluid protein – 60g/L

Serum protein – 65g/L
Pleural LDH – 54 u/L
Serum LDH - 166

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 6/9/2018

CHEST AP
Hospital Day 2 (2/17/18)
RECLINED PORTABLE
Problem Findings Assessment Plan (2/17/2018)
CHEST PAIN Serosanguinous Pleural Tuberculous For 12-Lead ECG
fluid-1550cc Pleural Effusion, ISDN 5mg tablet sublingual
O2 SAT- 98-99% Left s/p Start Dolcet mini 1 tab every
Decreased breath Ultrasound-guided 8 hours after meals
sounds- Thoracentesis Repeat chest x-ray
Mid to base lung
for ANA titer
Right shoulder pain

Parameter Released: 2/19/18

ANA Titer
1:80 dilution Negative
1:160 dilution Negative
1:320 dilution Negative

Hospital Day 3 (2/18/18) Hospital Day 4 (2/19/18)

Problem Findings Assessment Plan Problem Findings Assessment Plan
No subjective (-) Difficulty of Tuberculous Continue thoracentesis care No subjective (-) Difficulty of breathing Malignant Pleural Continue thoracentesis
complaints breathing Pleural Effusion, For TSH complaints 02-100% Effusion, Left T/C care
02-100% Left s/p Adenocarcinoma of For pull out of
Ultrasound-guided Cytology report: the lungs thoracentesis
Positive for Adenocarcinoma
Thoracentesis
Cytology Report (2/19/2018)
FINAL PATHOLOGICAL DIAGNOSIS: Positive for Adenocarcinoma

MICROSCOPIC EXAMINATION: Smears and cell blocks show several malignant cells seen singly and in
Parameter Released: 2/19/18
clusters, characterized by medium to large, round to ovoid pleomorphic generally vesicular nuclei with
TSH titer fine to coarse chromatin pattern and visible nucleoli.
TSH 3.61 uIU/ml Cytoplasm is scant to adequate and amphophilic, vacuolated or clear.
Cell blocks, in addition show the same malignant cells lining abortive and well formed glandular structures.

These are seen together with several mesothelial cells, histiocytes, lymphocytes and neutrophils on a
background of several red blood cells and amorphous material.

Hospital Day 5 (2/20/18)

Immunohistochemical Markers:
Problem Findings Assessment Plan
CEA
No subjective (-) Difficulty of Malignant Pleural For Chest CT-scan with
B72.3
complaints breathing Effusion contrast
02 - 99-100% secondary to For Whole Abdomen CT- Leu-M1
Adenocarcinoma scan (triple contrast) Calretinin
r/o primary vs For serum Creatinine Cytokerain 5/6
metastatic
For Carcinoembryonic
Antigen

Parameter Released: 2/20/18

Serum Creatinine 69.7 umol/L
Parameter Released: 2/21/18
CEA 6.39 ng/ml H

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CT-Scan Current Working Diagnosis

(2/22/2018)

Malignant Pleural Effusion secondary

to Adenocarcinoma, R/O Primary VS
Metastatic

Management of Pleural Effusion Thoracentesis

Identification and treatment of underlying disease Most common indication: pleural fluid >10mm thickness on lateral
decubitus CXR
Oxygenation In MPE:
Thoracentesis (Diagnostic and Expected response to systemic therapy

Therapeutic) Closed Tube Thoracostomy Short survival expectancy

Slow reaccumulation
Video-Assisted Thoracoscopic Surgery
Complications:
(VATS) Pleurodesis Pneumothorax
Hemothorax
Reexpansion pulmonary edema
Organ laceration

Closed Tube Thoracostomy/Indwelling

Pleural Catheter
Indications:
Frank pus
(+) organisms on gram stain
Parapneumonic effusion with evience of loculation
Pleural fluid: pH <7.1, glucose <40g/dL, LDH >1000
Massive effusion

No absolute contraindications
Relative contraindication: coagulopathy, thrombocytopenia

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Closed Tube Thoracostomy/Indwelling Pleurodesis

Pleural Catheter May be achieved by:

Indications for removal of CTT: Chest tube – best method

VATS
Drainage of <30-50 ml/day
Open thoracotomy with pleurectomy
Drainage fluid is clear yellow Pleuroperitoneal shunting
Improved symptoms
Sclerosing Agents:
CT dysfunction
Talc – most effective and most commonly used
Tetracycline
Spontaneous pleurodesis occurs in about 42% Doxycycline
of patients Bleomycin

Pleurodesis
THANK YOU!
Indications/requirements
Daily output of a drainage catheter <150mL Full
expansion of the lung on chest radiograph

Complications
Fever
Pain
Nausea
Respiratory
failure Death

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General Objectives

● At the end of this 1 hour session, the

clinical clerks should be able to recognize,
clinically diagnose and manage a patient with
Department of Surgery thermal burn 100% of the time, at all possible
settings and circumstances
Case Management Conference
BAYLA
MALIMBAN

Specific Objectives General Data

• To gather pertinent information through complete • AB

history and thorough physical examination.
• To discuss a complete plan of management with
diagnostics, therapeutics and supportive regimen
for the patient.
• 21 year old, Male
• Single, Filipino, Roman Catholic
• Born on August 25, 1996 at Dasmarinas, Cavite
• Currently residing at Dasmarinas City, Cavite
• Admitted for the first time at DLSUMC on April
13, 2018 at 11:16 PM

Chief Complaint

“Burn”
Primary Survey

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▶ Brought in via stretcher NOI: Flame Burn

▶ Vital Signs: TOI: 5:30PM
POI: Dasmarinas
▶ BP: 180/100mmHg DOI: 04/13/18
• HR: 89bpm
• RR: 25cpm
• T: 36.1C
• GCS 14, drowsy
• Multiple burn injuries on face and extremities
• In pain distress

Airway Breathing
Assessment Assessment
• (+) singed nasal hair • Symmetric chest expansion
• (-) obstruction
• No hoarseness
• (-) blood per orem
• No stridor
• (-) sooty phlegm
• RR : 25cpm
• (-) foreign bodies
• O2 Sat: 99%

Intervention
• Hooked to O2 support via nasal cannula at 3 lpm Intervention
• None

Circulation Deficit/Disability
Asessment
• BP: 180/100mmHg
Assessment
• HR: 89cpm
(+) GCS 14 (E3, V4, M6)
• Normal rate, regular rhythm no murmurs (+) sensory, motor and CN were not assessed
• Full equal peripheral pulses
Intervention
(+) None
Intervention
• None

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Exposure Fluids
Assessment
Assessment
(+) Flame burns 30% BSA, Deep partial to (+) Flame burns 30% BSA, Deep partial to full
full thickness bilateral lower extremities and left thickness bilateral lower extremities and left arm
arm (+) Estimated Body Weight: 80kg
Intervention
(+) Fast Drip PLR 1L
Intervention
(+) Removed patient’s clothes and (+) Regulate IVF:
dressed her in hospital gown #1 PLR 1L x 340cc/hr for 7 hours
(+) Wound dressing #2 PLR 1L x 340cc/hr for 7 hours

History of Present Illness

1 hour PTC Brought at a

different DLS-UMC
Patient sustained
flame burns on institution ER
SECONDARY SURVEY face, upper and Advised CONSULT
lower extremities transfer for
burn capable
institution

Past Medical History Family History

(+) A - no known allergies (+) (-) Asthma

(+) M - no maintenance medications (+) (-) DM
(+) P - unremarkable (+) (-) HPN and Heart Disease
(+) L - unknown by informant
(+) E - was smoking cigarette

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Personal and Social History Review of Systems

(+) General: (-) weakness (-)weight loss (-)chills (-) loss of appetite
(+) Smoker for just 2 months/5 sticks per day (+) SHEENT: (-)cyanosis (-)jaundice (-) edema (-)masses (-
)stiffness of neck (-)pain (-)discharge (-) BOV (-) nasal obstruction (-)
(+) Occassional alcohol drinker
epistaxis (-)dysphagia (-)sore throat
(+) No recreational drug use (+) Cardiovascular: (-) chest pain (-) palpitations (-) orthopnea
(+) GIT: (-)abdominal pain (-)constipation/diarrhea (-)nausea/vomiting
(+) GUT: (-)oliguria (-)dysuria (-) hematuria
(+) Endocrine: (-)polyuria (-)polydipsia (-)heat and cold tolerance
(+) Extremities: (-) joint pain (-)edema
(+) Hematologic: (-) easy bruisability

General Survey and Vital Signs

(+) Awake, conscious, coherent, oriented in three spheres
(+) Fairly developed, fairly nourished, appears his age
(+) In pain distress
PHYSICAL EXAMINATION (+) BP:180/100 mmHg;
(+) T: 36.1 C
(+) HR: 89
(+) RR: 25
(+) O2 Sat: 99%
(+) Weight: 80kg
(+) Height:

SHEENT
Chest and Lungs
(+) Skin: The skin is moist, smooth texture, with good
capillary refill, no cyanosis, pallor, jaundice or rash, noted. Inspection: (-) Chest deformities (-) retractions (-) use
(+) Head: Head is normocephalic and symmetrical with gray of accessory muscles; AP:T=1:2
hair evenly distributed.
(+) Eyes: Pupils 3mm equal and briskly reactive to light,
EOMs full and equal at all 6 cardinal directions of gaze, no Palpation: (+) Symmetrical chest expansion
excessive lacrimation.
(+) Ears: No lesion, mass, or deformity of Pinna or peri- Percussion: (+) Resonant in all lung fields
auricular area, external ear canal opening patent.
(+) Nose: Patent; no septal deviations. (-) discharge
(+) Throat: (-) cervical lymphadenopathies (-) thyroid gland Auscultation: Clear Breath sounds
not palpable (+) trachea midline (-) neck vein distention. (-) crackles (-) wheezes (-) rhonchi

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Heart Abdomen
th
Inspection: (-) precordial bulge; PMI at the 5 Inspection: Flat (-) scars (-) visible veins or pulsations
ICS LMCL
Auscultation: normoactive bowel sounds at
th 9/min, (-) bruit
Palpation: Apex beat at the 5 ICS LMCL,
no heaves no thrills Percussion: Tympanitic in all quadrants
Palpation: (-) tenderness (-) mass (-) organomegaly
Ausculatation: Normal rate at 89 bpm, regular
rhythm, S1>S2 at the apex, S1<S2 at the base, no
S3 or S4, no murmurs.

Extremities Neurologic
(+) (+)Swelling, (+)Redness,
(+)tenderness, (+)warm and GCS 14 (E3, V4, M6)
(+)edematous bilateral lower extremities
and left arm
(+) (-)Limitation of ROM
(+) Full and equal peripheral pulses

Primary Impression:
Flame burns 30% BSA Deep partial to full thickness bilateral lower
extremities and Left arm

COURSE IN THE ER

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Day 0 EMERGENCY ROOM Day 0 EMERGENCY ROOM

Time Subjective/Objective Assessment Plan Time Subjective/Objective Assessment Plan
Multiple burned skin on Multiple burned skin on
Arrival right upper extremity, Flame burns IVF: PLR 1L x 6 hours 1900H right upper extremity, Flame burns 30% For admission
1803H bilateral lower extremities 30% Partial Fast Drip PLR 1L (0057H) bilateral lower extremities Partial BSA, Deep Diagnostics:
and in the face partial to full CBC, Na, K, Creatinine
(00H) and in the face BSA, Deep Regulate IVF:
Urinalysis, 12L ECG, CXR PA
partial to full #1 PLR 1L x 340cc/hr for thickness Therapeutics:
VS: thickness 7 hours VS: bilateral lower NUBAIN 10mg IV
BP180/100 mmHg BP180/100 mmHg extremities and CEFUROXIME 1.5g IV
bilateral lower #2 PLR 1L x 340cc/hr for
PR – 89 bpm PR – 89 bpm ESOMEPRAZOLE 40mg IV
extremities 7 hours left arm
RR – 25 cpm RR – 25 cpm IG tet IM
T – 36.1C and left arm T – 36.1C
O2 – 99% Diagnostics: O2 – 99%
For EMERGENCY
Serum Na, K ESCHAROCTOMY; Change of
Burn Dressings

Laboratory
CBC
Hemoglobin – 151
Sodium – 136
Hematocrit - 0.46
Potassium – 3.7
WBC – 14.9H
Creatinine – 83.6
RBC – 5.8
Segmenters – 0.49L
Lymphocytes – 0.46H CHEST AP VIEW
Eosinophils – 0.01L -unremarkable
Basophils – 0.00
Monocytes – 0.04 COURSE IN THE WARDS
Platelets - 296

Hospital Day (4/13/18)

S O> A> P>

OR FINDINGS: FLAME BURNS 30% ESCHAROTOMY, BURN

15% full thickness burn left leg, TBSA, PARTIAL TO DRESSING (DONE)
distal thigh, circumferential with FULL THICKNESS
beginning compartment syndrome BURN. Escharotomy left lower extremitiy,
8% deep partial thickness burn, EXTREMITIES, FACE left hand, distal forearm
right leg Burn dressing with Flammazine
5% full thickness burn, left foeram cream
and hand Short arm splint left arm
1% partial thickness burn, right
forearm COMPARTMENT
1% superficial partial thickness SYNDROME, LEFT LEG
burn, face

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Hospital Day (4/16/18)

S O> A> P>

OR FINDINGS: FLAME BURNS 30% ESCHAROTOMY, BURN

15% FTB Left leg, distal thigh,
circumferential
8% DPTB right leg
5% FTB left foeram, hand
1% ptb Right forearm
1% SPTB face
TBSA, PARTIAL TO DRESSING (DONE)
FULL THICKNESS
BURN, EXTREMITIES, Escharotomy left lower extremitiy,
FACE left hand, distal forearm
Burn dressing with Flammazine
cream
Short arm splint left arm
Fucidin ointment over facial burns

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Hospital Day (4/20/18)

S O> A> P>

OR FINDINGS: FLAME BURNS 30% ESCHAROTOMY, BURN

15% FTB Left leg, distal thigh,
circumferential with beginning
compartment syndrome
8% DPTB right leg
5% FTB left foeram, hand
1% PTB Right forearm
TBSA, PARTIAL TO DRESSING (DONE)
FULL THICKNESS
BURN, EXTREMITIES, Tangential excision of eschar
FACE Split-thickness skin grafting done
(donor - bilateral thigh)
Split-thickness skin graft on
anterior left leg, secured using
staples, dressing with bactigras
Debridement and dressing using
Flammazine cream on other
extremities
Long leg splint on left leg

Hospital Day (4/26/18)

S O> A> P>

OR FINDINGS: FLAME BURNS 30% ESCHAROTOMY; CHANGE OF

Good Graft Take previous TBSA DEEP PARTIAL BURN DRESSING
escharotomy site -5% TO FULL THICKNESS,
BILATERAL LOWER
Superficial Partial Thickness burn EXTREMITIES, LEFT
left upepr extremity, right thigh and ARM
leg, and left thigh ~20%

Deep partial thickness burn on

anterior leg ~5%

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FINAL DIAGNOSIS

Flame burns 4% BSA Deep partial to full

thickness left lower extremity and left arm

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Overview of burn
management injury
RESUSCITATIVE PERIOD DEFINITIVE PERIOD
(First 48 hours) (>48 hours)
• Assessment of burn • Excision and Grafting
injury • Control of infection
• Classification of burn • Nutrition
CASE DISCUSSION injury • Rehabilitation
• Criteria for admission • Prevention and
• Initial ER management Management
Fluid Resuscitation Complication
Wound dressing
Monitoring

ETIOLOGY OF BURNS
FLAME BURN - direct contact with fire
FLASH BURN - intense heat for a brief period of time
SCALD BURN - contact with hot liquids
CONTACT BURN - contact with hot objects (metal, plastic, glass etc.)
CHEMICAL BURN
BURNS a. ACID BURNS: self-limiting
b. ALKALI BURNS: continue to dissolve skin until neutralized
ELECTRICAL BURN
High Voltage - >1,000 volts
Low Voltage - <1,000 volts
RADIATION BURN - laboratory accidents, x-ray machines, etc.

Assessment of Burn Depth

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Second Degree Burn Third Degree Burn

CLASSIFICATION OF BURNS
Fourth Degree Burn 1st degree burn 2nd degree burn 3rd degree burn 4th degree

(DEPTH)
Description
Epidermal
Tissue damage restricted to
Partial-Thickness Full thickness Burn
Involves the epidermis and Involves epidermis, dermis Involves bone, muscles and
epidermis and upper part of the dermis and subcutaneous tissue tendons
dermis

Cause Flash flame, ultraviolet Contact with hot liquids or Contact with hot, liquids or Prolonged contact with flame,
(sunburn) solids, flash flame or direct solids, flame, chemical, electrical
flame, UV electrical

Surface appearance Dry, no blisters, no or Moist blebs, blisters Dry with leathery eschar Same as 3rd degree possibly
minimal edema until debridement with seen bone, muscle and
Charred vessels are tendon
visible
Color Erythematous Mottled white to pink, cherry Mixed white, waxy; dark, Same as 3rd degree
red khaki, charred
Sensation Painful Very painful Decreased sensation intact Little or no pain (nerves are
deep –pressure sensation destroyed)

Healing time 3 to 6 days 10 to 21 days More than 21 days Grafts needed

(7-10days) (SPTB - 2-3wks Grafts / Skin coverage
DPTB - 3-5wks > needed
hypertrophic
scarring/contractures)

Overview of burn management

injury
RESUSCITATIVE PERIOD DEFINITIVE PERIOD
(First 48 hours) (>48 hours)
Criteria for Admission
• Assessment of burn • Excision and Grafting
injury • Control of infection
• Classification of burn • Nutrition
injury • Rehabilitation
• Criteria for admission• Complication
• Initial ER management
Fluid Resuscitation
Wound dressing
Monitoring

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Burn Severity Categorization

ESTIMATIN
G EXTENT
OF BURN
INJURY

Overview of burn
management injury
RESUSCITATIVE PERIOD DEFINITIVE PERIOD
(First 48 hours) (>48 hours)
• Assessment of burn • Excision and Grafting
injury • Control of infection
• Classification of burn • Nutrition
injury • Rehabilitation
• Criteria for admission • Complication
• Initial ER
management Fluid
Resuscitation Wound
dressing Monitoring

Initial ER Management
• Primary Survey • Secondary Survey
A-irway • A -llergies
B-reathing • M –edications/Tetanus
Immunization
C-irculation
• P – revious Illness
D-isability/Deficit
• L –ast meal or drink
E-xposure
• E – vents preceding the injury
F-luid Resuscitation

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Estimated body weight: • Cool wound with tap wate

Minor Burns • Clean with soap/betadine
scrub and water
• Wound care, debridement of
• 0.9 x [ 172cm - 100 ] dead tissue and analgesics
• 64.8 • No systemic prophylactic
• PARKLAND FORMULA: antibiotics are given
• 4ml x BSA(%) x weight (kg) • Tetanus Prophylaxis
• = 4ml x 30 x 80kg (ESBW)
• Apply ointment and nonstick
• = 4ml x 30 x 80kg
porous gauze
• = 9600cc
• = 4800cc for the first 8 hours
• Then another 4800cc for the next 16 hours

Moderate, Major • Employ ABCs trauma Overview of burn

and Critical Burns
• Sterile gloves while examining
• Remove all burnt clothing management injury
• Suspect inhalational injury
• Intubate if burns > or =50% BSA RESUSCITATIVE PERIOD DEFINITIVE PERIOD
• Fluid Resuscitation (First 48 hours) (>48 hours)
• Foley catheter and NGT
• Estimate body weight • Assessment of burn • Excision and Grafting
• Tetanus prophylaxis, H2 injury • Control of infection
blockers • Classification of burn • Nutrition
• Escharotomy injury • Rehabilitation
• Criteria for admission • Complication
• Initial ER
management Fluid
Resuscitation Wound
dressing Monitoring

DEFINITIVE MANAGEMENT Topical Antimicrobial Agents

Early (within 7 days post burn) excision of the burn • Bacitracin
wound followed by skin grafting For gram positive bacteria, good for facial care and
epitheliazing wounds
Attention to nutrition • Mafenide
Broad spectrum antibacterial and anticlostridial
Pain management Penetrates eschar (available as solution or cream)
Painful on application and causes metabolic acidosis
Rehabilitation via carbonic anhydrase inhibition
• Mupirocin
Management of Complication Anti-MRSA, poor gram negative antimicrobial coverage

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Topical Antimicrobial Agents Topical Antimicrobial Agents

• Nystatin
• Silver Nitrate
Broad spectrum antibiotics, effective for both
prophylaxis and treatment
7. Daikin Solution
Penetrates eschar poorly, causes hyponatremia 15ml of sodium hypochlorite (zonrox) +
Induces methemoglobinemia 985ml PNSS
6. Silver Sufadiazine Broad spectrum
Broadspectrum antibacterial, antipseudomonal antibacterial Inexpensive
penetrates eschar poorly causes leukopenia Chlorine compounds causes skin
redness, irritation and swelling

WOUND DRESSING

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Complication
Burn wound sepsis
Acute respiratory distress syndrome
Abdominal compartment syndrome
Deep vein thrombosis
Stress Ulcers (Curling ulcers)
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Criteria for discharge
• No existing complications of thermal injury
such as inhalational injury
• Fluid resuscitation completed
• Adequate pain tolerance
• Adequate nutritional intake
• No anticipated septic complications
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THANK YOU!