Adventist Medical Center – Iligan

Department of Pediatrics

Case Mortality

September 26, 2019

 General Data
• J.L.
• 15 years old
• Female
• MSU Campus, Marawi City
• Filipino
• Islam
• Admitted: August 9, 2019
Chief Complaint

Vomiting
 History of Present Illness
• 4 months PTA
– patient had recurrent vomiting associated with
abdominal pain and LBM
– Consulted at government hospital and managed
as AGE with Moderate Dehydration, Acute
Pyelonephritis R/O AP
– Eventually discharged improved after 7 days
 HPI
• 1 week from being discharged, patient had
recurrence of vomiting, hence follow-up at
same institution.
– Prescribed with unrecalled medications with no
relief
– Consulted back and was advised for Gastro
consult
– Hence referred in our institution
 HPI
• 3 months PTA
– Patient was admitted due to persistence of above
s/sx and managed as Bilateral Pyelonephritis
– Improved and discharged after 7 days
– 1 week from discharged, vomiting recur, this time
no consult or follow-up done
– Condition tolerated
 HPI
• 2 months PTA
– Decided to consult at private institution in Cebu
– Further evaluation and management was done
(Gastro, Nephro), underwent Colonoscopy and
Endoscopy, however on the 8th hospital stay,
patient went HAMA
 HPI
• On interim, condition was tolerated, no
follow-up or consult done
• 2 days PTA, noted inability to void, hence
consulted at government hospital in Marawi,
but eventually referred and transferred to
government hospital in Cagayan de Oro
– Further evaluation done noted elevated creatinine
– Hence adviced for Hemodialysis but refused and
went HAMA
 HPI
• ODA
– Noted persistent bilious vomitus
– Hence opted admission in our institution
 Past Medical History
• Previous Hospitalizations:
– April 2019: Bilateral Pyelonephritis
– July 2019: Mild Chronic nonspecific Esophagitis,
Mild Chronic nonspecific gastritis, Mod-severe
Chronic duodenitis, Chronic nonspecific Ileitis,
Chronic nonspecific colitis
• No known food and drug allergy
• NonAsthmatic
 Family History
• Father: 48 years old – policeman
• Mother: 47 years old – teacher
• Siblings: 4/7
– 23/F
– 21/F
– 17/M
– 10/M
– 9/M
– 7/M
 Heredofamilial Diseases
• (-) BA
• (-) DM
• (-) HPN
• (-) Convulsion
• (-) Cardiac disorder
• (-) Congenital Anomalies
 Birth History
• Mother had PNCU
– 2 months AOG, regular follow-up
– No known maternal illness
– (+) TT (+) MV, Fe, FA
• Delivered, Term, NSD, with good activity, no
complications
• NBS - Normal
 Social/ Environmental
• (-) Exposure to cigarette
• Water source: Tap water
• Number of people living in the house: 9
• Garbage disposal: Regular
• Education: Grade 9 with average performance
 Immunization
• Completed EPI
• Local health center
 Review of Sytems
• Skin: (-) rashes (-) pigmentation
• Head: (-) Headache (-) Dizziness
• Eyes: (-) nystagmus (-) Redness
• ENT: (-) Hearing loss (-) Epistaxis (-) Sore throat
• Respiratory: (-) Cough (-) DOB (-) Chest pain
• CVS: (-) Cyanosis (-) Fainting spells
• GI: (+) Vomiting (-) Diarrhea
• Hematologic: (+) pallor
• Neurologic: (-) Seizure (-) Paralysis
• Musculoskeletal: (-) Swelling (-) Joint pains (-) Body malaise
• GUT: (-) Edema (-) Dysuria
 Physical Examination
• Awake, weak-looking, not in cardiopulmonary
distress
• Vital signs:
– BP 100/60 Wt 38.5 kg
– HR 124 Ht 104cm
– RR 18
– Temp 36
– O2sat 96%
• Skin: warm, dry, poor turgor (-) lesions (-) rashes
• Head: Atraumatic (-) Lumps
• Eyes: sunken, Pale palpebral conjunctivae
• Mouth: Moist lips
• ENT: (-) Discharges (-) Alar flaring
• Neck: Supple, No mass, (-) LAD
• Chest: ECE, Clear BS
• CVS: AP, Tachycardic, Normal rhythm
• ABD: Flat, Soft, (+) Tenderness (-) Hepatomegaly
• Genitalia: Grossly female,+ rashes
• Rectal: Patent
• EXT: Full pulses, CRT <2sec
• Neurologic: (-) Deficit
Admitting Impression

Chronic Gastritis
T/C AKI
T/C Sepsis
 At ER (D3 illness)
• Admit • Medication
• Consent to care – Ranitidine
• VS q 2H – Metronidazole IV
– Ceftriaxone
• NPO – Nahco3 q8H
• Diagnostics: – Metroclopramide
– CBC PC, BT, SGPT, Na, K, Ca,
ABG, HGT, CXR • I&O
• IVF: D50.3 at MR • Insert FBC
• For close watch
• Refer to Gastro - comgt
• Refer for any unsualities
 Blood Normal

Diagnostics Chemstr
y
values

Na 150.4 135-148
CBC ER Normal K 2.06  3.5-5.3
Value Ca 1.96  2.2-2.7
Hgb 90 110-180
Hct .29 .37-.47 Crea 413.07 53-106
WBC 23.65 5-10 HGT 116
Seg .88 .50-.65 ABG
Lymp .11 .25-.35 O2sat 98.8
Mono 0.01 .03-.07 pH 7.446
Eo 0 01-.03 pO2 115
Plt 368 140-450 PC02 25.5
BT O+ BE -6.5
HC03 17.5
Total C02 18.3
 1st HD
S O A P
(+) Fever Awake, weak, not Chronic Gastritis Main service:
+vomiting-bilious CPD T/C AKI Fast drip at 7cckg-
+restless BP 100-110/60-70 T/C Sepsis >D5LR
+body pains HR 100-110 Start KCL drip
+BM: clear, mucuid RR 22-24 Vol/Vol replacemnt
stool T 36-38 GI losses: PNSS+KCL
O2sat 98% APPRAISED FOR
Ou 0.03cckgx24 DIALYSIS
Midazolam PRN x
Cachectic restless
Dry skin Ceftri1, Metro1
Poor turgor Gastro:
Clear bs Insert NGT
Soft abdomen, Transfuse 1 unit
tender at PRBC
hypogastric area Rpt Crea
Warm, strong pulse Tramadol IV drip
 2nd HD
S O A P
(+) Fever Awake, weak, not Chronic Gastritis Main servive:
+vomiting-bilious CPD Tc AKI Cont IVF
+restless BP 100-110/60-70 Tc Sepsis Calmoseptine
+body pains HR 100-110 cream
+rashes at genital RR 23-24 Ceftri2, Metro2
and buttocks area T 36-37
O2sat 98% Gastro:
Ou 13ccx24 Start Furosemide
drip
Cachectic Start Dopamine
Dry skin drip (renal dose:6)
Poor turgor Tramadol IV drip
Clear bs
Soft abdomen,
tender at
hypogastric area
Warm, strong pulse
 Laboratory Results
Chest Xray: Pneumonia both lower lungs

Blood Chemstry 1st HD

Na 150.4 156
K 2.06  2.24
Ca 1.96 
Crea 413.07 677.29
HGT 116
 4th HD
S O A P
+cough Awake, weak, not CPD Chronic Gastritis Main servive:
+vomiting-bilious BP 100-110/60-70 Tc AKI Cont IVF
+restless HR 100-110 Tc Sepsis Calmoseptine cream
+body pains RR 22-24 Ceftri4, Metro4
+rashes at genital and T 36-38 FOR PERITONEAL
buttocks area O2sat 98% DIALYSIS
Ou 0.03cckgx24
Gastro:
Cachectic Start Furosemide drip
Dry skin Start Dopamine drip
Poor turgor (renal dose:6)
Rales BLF Tramadol IV drip
Soft abdomen, tender
at hypogastric area Gastro service – sign
+rashes at genital aprt out (No further GI
to buttocks instrumentation)
Warm, strong pulse
 5th HD
S O A P
+cough Awake, weak, not CPD Small Bowel Main servive:
+vomiting-bilious BP 100-110/60-70 Obstruction probably Cont IVF
+restless HR 100-110 sec to Malrotation, Calmoseptine cream
+body pains RR 22-24 AKI sec to DHN Ceftri5, Metro5
+rashes at genital and T 36-38 Malrotation FOR PERITONEAL
buttocks area O2sat 98% DIALYSIS
Ou 0.5cckgx24 Start Furosemide drip
Start Dopamine drip
Cachectic (renal dose:6)
Dry skin Tramadol IV drip
Poor turgor Rpt CBC,Crea, K, NA
Rales BLF REFER TO PEDIA
Soft abdomen, tender SURGERY:
at hypogastric area
+rashes at genital aprt
to buttocks
Warm, strong pulse
 Surgery Plan
• Suggest to continue hydration
• Suggest hemodialysis for possible surgical
abdomen
• Abdominal XRY/high back rest and plain
abdominal xry
• For UGIS
 Diagnostics
CBC ER 5th HD Abdominal Xry Small Bowel Ileus, Ascites
Hgb 90 138
Hct .29 0.41
WBC 23.65 9.29
Blood 1st HD 5th HD
Seg .88 .90 Chemstry
Lymph .11 .08 Na 150.4 156 158
Mono 0.01 .01 K 2.06  2.24 2.90
Eo 0 .01 Ca 1.96 
Plt 368 180 Crea 413.07 677.29 329.4
BT O+ HGT 116
 7th HD
S O A P
+cough Awake, weak, not CPD Small Bowel Main servive:
+vomiting-bilious BP 100-110/60-70 Obstruction prob sec Cont IVF
+restless HR 100-110 to Malrotation, Calmoseptine cream
+rashes at genital and RR 22-24 AKI sec to DHn Ceftri->PipTaz3,
buttocks area T 36-38 Metro7
O2sat 98% Furosemide drip
Ou 0.03cckgx24 Dopamine drip (
Tramadol IV drip
Cachectic Vit K
Dry skin Salbutamol q8
Poor turgor
Rales BLF Surgery:
Soft abdomen, tender Schedule for EXLAP:
at hypogastric area Moderate Risk
+rashes at genital aprt Stratification
to buttocks Give 20% Albumin
Warm, strong pulse
Surgery Notes:
• Procedure:
– EXLAP, LADDS Procedure
• Pre—operative Dx:
– Complete Intestinal Obstruction prob sec to
Malrotation
• Intra-op:
– Malrotation, located at midvertebral area way below
the level of Gastric Outlet
• Post-operative Dx:
– Malrotation
 8th HD (Post-Op)
S O A P
Sedated Lethargic Malrotation Main servive:
BP 70-90/40-60 AKI sec to DHn Cont IVF
HR 127-153 Calmoseptine cream
RR 22-24 Ceftri4->PipTaz4,
T 36-37.6 Metro8
O2sat 98% Furosemide drip
Ou 0.3cckgx24 Dopamine drip
Tramadol IV drip
Anasarca Salbutamol q8
Decreased BS at LLF O2
Postsurgical site Surgery:
+rashes at genital aprt Na, K, Crea
to buttocks For UTZ-guided
Cold, strong pulse Thoracentesis L Chest
 Diagnostics
CBC ER 5th HD 8th Chest Xray: Moderate Left Pleural Effusion
Hgb 90 138 102
Hct .29 0.41 .32
WBC 23.65 9.29 7.57
Blood 1st HD 5th HD 8th HD
Seg .88 .90 .82 Chemstry
Lymph .11 .08 .16 Na 150.4 156 158 148.9
Mono 0.01 .01 .01 K 2.06  2.24 2.90 2.97
Eo 0 .01 .01 Ca 1.96  .86
Plt 368 180 110 Crea 413.07 677.29 329.4 199.84
BT O+ 
HGT 116 135
Albumin 19
 10th HD
S O A P
Seizure Lethargic Malrotation Main servive:
+anasarca BP 70-90/40-60 AKI sec to DHn Cont IVF
+coffeeground NGT HR 127-153 UGIB Calmoseptine cream
output RR 22-24 Ceftri4->PipTaz6,
T 36-37.6 Metro10
O2sat 98% Furosemide drip
Ou 0.3cckgx24 Dopamine drip
Tramadol IV drip
Anasarca O2
Decreased BS at LLF Rpt CXR: Pleural
Postsurgical site effusion LLF
+rashes at genital aprt Surgery:
to buttocks REFER tp Pulmo
Cold, strong pulse REFER to Neuro
REFER to Ophtha
 PULMO NOTES NEURO NOTES
• Maintain on O2 • Start Levetiracetam
• Nebulize with • Diazepam PRN
Fluimucil
• For Cranial CT scan
• Start Azithromycin IV
 Ophtha NOTES
• Fundoscopic Exam:
– No edema
– (+) Hemorrhage R eye

• Assessment:
– Seizure prob sec to Encephalopathy, Multifactorial
– R/o Spontaneous ICH
• PLAN:
– Inc Levetiracetam
– Citicoline
 Ultrasound-Guided Thoracenthesis
(1 liter of Pleural Fluid)

PLEURAL FLUID
• CELL COUNT
– Red cells: 198
– White celss: 56 cells
– Lymphocytes: 97%
– Polymorph: 3%
• AFB: No microorhanism seen
• TRANSUDATIVE PLEURAL FLUID
 12th HD
S O A P
+difficult IV insertion Drowsy Malrotation Intubation
Apneic BP 80-90/50-60 AKI sec to DHn
HR 130-170 UGIB
RR MV Seizure prob sec to
T 36.6-38.1 Encephalopathy,
O2sat 99% Multifactorial
Ou 0.3cckgx24

Cold clammy skin

Faint pulses
 13-14th HD
S O A P

GCS 3 BP Palpatory 60-80 Malrotation FAMILY APPRAISED OF

AKI sec to DHn PATIENTS CONDITION,
UGIB PROMPTED FOR
Seizure prob sec to HAMA
BP UNAPPRECIATED Encephalopathy,
HR 130-170 Multifactorial
RR MV
T 35.5
O2sat 100%
Ou 0.3cckgx24
FAMILY REAPPRAISED
Cold clammy skin
Faint pulses
DNR
 FINAL DIAGNOSIS
MALROTATION
AKI SEC TO SEPTIC SHOCK
METABOLIC ENCEPHALOPATHY,
MULTIFACTORIAL
SEIZURE SECONDARY, CONTROLLED