1. Mortality Audit December 2014 GENERAL SERVICE 2 CHANG/CACAYORIN/DOMINGUEZ

2. GENERAL INFORMATION  FA  5 month old, Female  Quezon City  Roman Catholic  Date of Admission: 12/29/2014  CHIEF COMPLAINT: “nanuyo na siya” (dry lips and body)

3. History of Present Illness 3 days prior (+) 4 postprandial vomiting episodes, ¼ cup per bout (+) 6 episodes of watery, yellowish, nonbloody stool (+) decreased appetite (+) fever Tmax 38 Cough 2 days prior Persistence of fever and occasional cough cough (+) 2 episodes of vomiting of the same amount (+) 3 episodes of watery stool (-) consult Few hours prior Consult with a general physician done Advised admission Assessment was bronchopneumoni a and acute gastroenteritis with severe signs of dehydration

4. Review of systems  (+) rashes at the perineal area  (-) jaundice  (-) diarrhea  (-) constipation  (-) dysuria  (-) oliguria  (-) melena  (-) hematochezia  (-) body/ joint pains  (-) easy bruisability  (-) prolonged bleeding

5. Birth and Maternal History  Born to an 18 year old G2P2 (2002), nonsmoker, non- alcoholic beverage drinker, with regular prenatal check-up at a Local Health Center since 3 months AOG with a midwife  (+) UTI at 7 months AOG given Amoxicillin for 7 days  (+) URTI at 5 months, (+) use of Multivitamins and Folic acid, noted maternal hypertension with no medication  Born full term via normal spontaneous delivery at a lying in clinic, delivered by a midwife (+) good cry and activity, discharged after 1 day, (-) meconium staining, (-) cord coil BW 2.7 kg with bowel movement and urine output on the first day  (-) Newborn screening (-) hearing screening

6. Nutritional History  Breastfed for 3 months  Milk formula from 3 months onwards  Currently taking milk 5 oz every 3 hours

7. Family History 22 year old 19 year old 2 year old (-) malignancy (-) hypertension (-) bronchial asthma (-) DM Laborer Housewife

8. Immunization History  BCG x1  Hep B, HIB, DPT, OPV x 2

9. Developmental History  Head control: 3 months  Social smile: 2 months  Hands not fisted: 2 months  Rolled over: 5 months  Laughs out load: 5 months

10. Past Medical Illness  (-) Previous admission  (-) Allergies  (-) Surgery  (-) head trauma  (-) accidents

11. Environmental and Personal Social History  Fairly lit, well ventilated one storey and one room house  Mineral water source  Regular garbage collection  4 household members  Second hand smoker exposure  No history of travel  No exposure to Measles, Mumps, Varicella  No pets at home

12. Physical Examination At the ER: 12/27/14 Awake, weak-looking, with weak cry, carried by mother BP 70/40 HR 120 regular RR 30 T 37.1 Sunken anterior fontanelle Multiple hypopigmented plaques over the scalp with crusts and scales Pink palpebral conjunctiva Dry lips, dry mucosa Supple neck, no neck masss Symmetric chest expansion, no retractions, crackles bilateral lung field

13. Physical Examination At the ER: 12/27/14 Adynamic precordium, normal rate regular rhythm, no murmur Soft abdomen, liver 2 cm from the subcostal area, nonpalpable spleen Warm extremities No edema Poor skin turgor, full pulses

14. Neurologic Examination  GCS 15: CN 1- not assessed  CN 2: (+) ROR, (-) papilledema bilateral, (+) pupils isocoric, equally reactive to light  CN 3, 4, 6: (+) doll’s eye  (+) Corneal reflex  CN 7: (-) facial asymmetry  CN 9 and 10: (+) gag  CN 12: tongue midline  No nuchal rigidity  (-) Clonus,  (-) Spasticity LE  (+) Babinski, B  DTR 2+ right, 2+ left

15. Salient Features 5 month old female With an acute history of cough, fever and diarrhea With poor intake for three days No Rotavirus vaccine With dry lips, mucosa, poor skin turgor Occasianal crackles in bilateral lung field

16. Working Diagnosis PCAP C Acute Gastroenteritis with severe dehydration 16

17. Course at the ER- 1st HD Course at the ER- 1 st HD SOAP Awake, HR 122, RR 30 BP 70/40, Temp 37.1 Sunken eyeballs, dry skin, dry oral mucosa, symmetric chest expansion, occasional cracles bilateral lung field, CRT <2 s Hgt 136 Chest xray: perihilar infiltrates Urinalysis; Straw, clear, sg 1.004, pH 5, no blood, no protein, RBC 3, WBC 4 Stool exam: green, mucoid, WBC 0-1, RBC 0, no ova or parasite AGE with Severe dehydration, PCAP C Admit to ER IVF decreased to Plain NSS (sevre) x 6 hours Ampicillin 100

18. Course at the ER- 1st HD 6th Hour Course at the ER- 1 st HD 6 th Hour SOAP Awake, HR 142, RR 36 BP 80/40, Temp 37.1 Eyeballs not sunken, dry lips, dry mucosa, CRT <2, full pulses CBC: hgb 82, hct 25, wbc 18.6, pmn 69 lym 29, plt 514 With toxic granules Na 130, K 2.2, Cl 108, Ca 1.26 Post hydration: ABG ph 7.3, pco2 16, p02 187, so2 100, hco3 8.1, be -15 Post bicarbonate correction: pH 7.55, pc02 25, po2 126, so2 99, Hco3 21.9, BE 0.8 AGE with Severe dehydration, PCAP C T/C sepsis IVF decreased to Plain NSS (mild) x 6 hours KCL incorporation Gentamicin (5) added NaHCO3 given

19. Course at the ER: 2 nd HD For transfer to Ward SOAP Awake, weak cry, palpatory 70, HR 160, RR 40, T 36.5 Symmetric chest expansion, no retraction, crackles bilateral lung field, adynamic precordium, tachycardia, no rhythm Post bolus: BP 90/60, HR 160s Hypovolemic shock secondary to severe AGE AGE with Severe dehydration, PCAP C PNSS 20 cc/kg 02 at 10 lpm NPO Hook to cardiac monitor and continuous pulse oximetry Refer to RICU PNSS 10 cc/kg in 1 hour

20. Course at the ER: 2 nd HD SOAP After 10 cc/kg for 1 hour, BP 80/50, RR 134 ABG: 7.36, pco2 28, po2 93, hco3 15.8, so2 97%, be -8.3 BUN 2.7 Crea 41 RBS 5.8 TPAG: 36/16/20/0.8 TB, DB IB: 0.35/0/23/ 0.11 PT PTT: 12.9/ 11.8/ 84%/ 1.08; 30.7/29.2 CBC: Hgb 59, Hct 0.18, WBC 14, pmn 60, lym 39, plt 455 Hypovolemic shock secondary to severe AGE AGE with Severe dehydration, PCAP C PNSS 30 cc/kg for 1 hour then 70 cc/kg for 5 hours For LDH, coombs reticulocyte Refer to PIDS for cefotaxime PRBC transfusion

21. Course at the ER: 2 nd HD 14 th hour SOAP BP palpatory 60, HR 130 BP palpatory 60, HR 140s BP palpatory 60, HR 154, RR 48 weak looking, drowsy Loose Stool noted to be yellowish green BP palpatory 50 Blood CS (-) Stool CS TACS, TAGS (-) T/C septic shockPNSS 20 cc/kg Voluven 20 cc/kg Dobutamine 10 Norepinephrine 0.5 Intubated ET 4 level 11 RSI: Midazolam + lidocaine Voluven 20 cc Norepinephrine 0.7

22. Course at the ER:Admit to RICU room C SOAP Awake, intubated, with reddish frothy output per ET HR 130, T 37, BP 70/40, crackles bilateral lung field ABG: ph 7.31, pco2 26, Po2 144, so2 99, be 13.1, be -11.6 Septic shock AGE, severe PCAP DCeftriaxone Gentamicin Hook to Mechanical ventilator FIO2 100, PIP 16, PEEP 6, RR 25

23. Course at the ER: 3 rd HD, PICU Day 2 SOAP Awake, comfortable, not in distress, HR 130, BP 80/50, febrile, non sunken eyeballs Impacted cerumen bilateral, Fine crackles bilateral lung ABG: ph 7.4, pco2 34, po2 309, so2 100, hco3 21.6, be - 2.6 Na 135, K 1.7, Cl 97, Ca 1.58 ALT 23, AST 1.58 Na 124, K 1.6, Cl 95, Ca 1.53 Septic shock AGE, severe PCAP D Ceftriaxone Gentamicin pRBC transfusion IVF D5NSS + 6 meq KCL (KIR 0.24) Hook to cardiac monitor Refer to surgery for central line insertion Central line K correction

24. Course at the ER: 3 rd HD, PICU Day 2 -14 th hour SOAP Awake, comfortable, not in distress, BP 80/60, HR 146, RR 32, warm extremities, full pulses K 5.5, Ca 1.63 Septic shock AGE, severe PCAP D Dec Dobu Shift NE to Epi Discontinue KCL incorporation Ca gluconate Start feeding

25. Course at the ER: 4 rd HD, PICU Day 3 SOAP Awake, comfortable, not in distress, HR 155, palpatory 60, facial edema, cold extremities, full equal pulse Still with 4 episodes of loose bowel movement 80/50, HR 140s Na 135, K 2.2, Cl 99, Ca 1.73 TPAG: 26/11/15/0.7 ALT 33, AST 45, BUN 1.2, Crea 33 ABG with HC03 correction: ph 7.14  7.45, pco239  41, po2 358, hco313.3  28.5, be -15  4.10, so2 100 Septic shock AGE, severe PCAP D PNSS 20 cc/kg bolus Voluven 20 cc/kg x 2 Hydrocortisone Increase NE 0.3 to 0.5 Dobu 10 Start Midazolam drip

26. Course at the ER: 4 rd HD, PICU Day 3 9 th hour SOAP BP 0 CR 115, Cold extremities Fair distal pulses BP 80/50, HR 150s SCE with shallow retractions Septic shock AGE, severe PCAP D Voluven 20 cc/kg Increase NE 0.5 to 0.7 Dobu 10 Give FFP Refer to PIDS to start Piperacillin Tazobactam PIDS: Start Meropenem Hold Midazolam drip Voluven 20 cc/kg

27. Course at the ER: 5th HD, PICU Day 4 SOAP Awake, comfortable, not in distress, HR 130, BP 80/50, febrile, non sunken eyeballs Impacted cerumen bilateral, Fine crackles bilateral lung Generalized edema Septic shock AGE, severe PCAP D Decrease IVF to 1.5x mtn Decrease Dopa 8 Decrease NE 0.5, Dopamine to 5

28. Course at the ER: 6th HD, PICU 4 th hour Day 5 SOAP Asleep, SBP 90, DBP not audible Good pulse. Crackles bilateral lung field Full pulses Generalized edema Cumulative FB +1329 Bradycardia 70, BP 0  HR 0 ABG: pH 7.41, pco2 34, po2 190, s02 100, hco3 21.6, be - 2.4 Stool exam: normal Septic shock AGE, severe PCAP D IVF: mtn - drip/oral CPR x 30 minutes

29. Septic shock Acute gastroenteritis with severe dehydration pneumonia Mortality Diagnosis: