1. General Data C.D. Age/Sex/Status: 81/F/Widow Address: San Miguel, Manila Date of birth: May 19, 1929 Place of birth: Manila Occupation: Unemployed Religion: Roman Catholic

2. Chief Complaint Difficulty of breathing

3. History of the Present Illness 7 days PTA Productive cough with yellowish sputum, not accompanied by DOB or fever Temporarily relieved with ambroxol HCl 1tsp Decrease in appetite No consult done 3 days PTA Persistence of cough DOB and low grade fever (38.0°C) Self –medicated with paracetamol 500mg/tab  Lysis of fever 7 hours PTA Choked after swallowing food  Went to the bathroom and came out with gradual decrease in level of sensorium DOB Difficulty in ambulation Admission

4. Past Medical History Head trauma (May 2009) – UST Neurosurgery (CT Scan unremarkable) (-) HPN, DM, CA (-) Thyroid disorders (-) Asthma, Allergies, PTb (-) Previous blood transfusion

5. Personal and Social History Mixed Diet Nonsmoker Non-alcoholic beverage drinker No illicit drug use

6. Family History Gallstone – sister HPN – brother (-) DM (-) CA (-) Asthma, PTB

7. Review of Systems General: no weight loss Skin: no rashes, no sores, no itching Head: no headache, no dizziness Eyes: no blurring of vision, no redness Ear: no ear pain, no discharge Nose: no epistaxis Throat: no sore throat Neck: no nape pain, no stiffness Cardiovascular: no chest pain, no easy fatigability, no PND Gastrointestinal: no diarrhea, no constipation, no vomiting Genitourinary: no hematuria, no dysuria Musculoskeletal: no joint pain, no swelling Endocrine: no heat and cold intolerance, no excessive sweating, no polyphagia Hematopoetic: no easy bruisability

8. Physical Examination upon Admission Lethargic, incoherent, stretcher-borne, hyposthenic, in cardiorespiratory distress BP 140/80 PR 105bpm RR 26 T 37.8ºC Weight : 45kg Height : 4’10 ‘’ BMI : 20 Warm, dry skin, no active dermatoses, no rashes Incisional scar on occipital área, no hair thinning Pink palpebral conjunctivae, anicteric sclerae, pupils 1-2mm ERTL No nasoaural discharge, no alar flaring Moist buccal mucosa, (+) food particles in mouth, non-hyperemic posterior pharyngeal wall Rigid neck, no palpable lymphadenopathies, thyroid not enlarged Symmetrical chest expansion, (+) subcostal and intercostal retractions, (+) crackles on both lung fields, vocal fremiti and tactile fremiti cannot be assessed Adynamic precordium, AB 5 th LICs MCL, S1>S2 at the apex, S2>S1 at the base, no murmurs, lifts, thrills, heaves Flabby abdomen, soft, non tender, no masses Pulses were full and equal, no cyanosis, no edema

9. Neurological Examination Lethargic,(+) spontaneous respiration, refuses to open eyes, no verbal output (intubated), localizes to pain, GCS 9 (E3V1M5) CN: Pupils 1-2 mm ERTL, no visual threat, (+) corneal reflex OU, brisk Motor: no preferential weakness, can maintain both lower extremities against gravity DTRs ++ on all extremities (+) Bilateral Babinski, more consistent on the left Meningeal signs: (-) Nuchal rigidity, (-) Kernig’s Rigidity on all directions of neck movement

10. CAD, NSTEMI 3/22/10

11. Course in the Wards ADMISSION: – ECG: sinus rhythm and diffuse ischemia. – Troponin I : elevated – Medications: Trimetazidine 35mg/tab 1 tab BID, Clopidogrel 75mg/tab 1 tab OD, ISMN 30mg/tab 1 tab OD, Atorvastatin 80mg/tab 1 tab ODHS, Metoprolol 50mg/tab 1 tab BID, and Fondaparinux 2.5mg/SC OD were then started – Repeat ECG: showed sinus rhythm and ST-T wave changes due to ischemia or hypokalemia

12. Course in the Wards On the 14 th HD: 2d echo with Doppler: normal left ventricle with interventricular septal hypertrophy with good wall motion and contractility and normal resting systolic function, calcified mitral valve annulus and mild aortic regurgitation, mild mitral regurgitation and mild tricuspid regurgitation with EF of 75%

13. Course in the Wards On the 19 th HD patient’s BP was 200/100, Medications: – Nicardipine drip started at 10mg + 90cc PNSS to un at 3cc/hr, titrated by 22cc/hr for systolic BP control to 110-130mmHg

14. Course in the Wards On the 41 st HD ECG: showed normal sinus rhythm with marked sinus arrythmia, Premature ventricular complex in couplet, occassional, premature atrial complexes. So Medication: – Clopidogrel 75mg/tab 1 tab OD continued

15. Course in the Wards On the 46 th HD, patient developed atrial fibrillation ECG: normal sinus rhythm with isolated premature atrial complex in V6. Medication: – Amiodarone 300 mg/IV was given and was maintained at 200 mg/tab OD – Carvedilol 6.25 mg/tab 1 tab OD

16. Course in the Wards On the 51 st HD Increasing trend in BP (140/90 to 160/100) Medication: – Losartan 50 mg/tab OD On the 72 nd HD, Medication: – Trimetazidine 75 mg/tab 1tab BID – Omacor 1 tab OD were started

17. Course in the Wards On the 101 st HD, – Trimetazidine, Omacor, and Duxaril was discontinued On the 102 nd HD, – amlodipine was put to hold, because patient has stable blood pressure(100-120/70-80) for the past month. On the 103 rd HD, – clopidogrel 75 mg/tab 1 tab OD was resumed.

18. CAD, NSTEMI Outcome: Unresolved

19. Decreased sensorium 3/22/10

20. Course in the Wards Admission patient was noted to be lethargic, GCS9 (E3V1M5) referred to Neurology – Assessment: Metabolic encephalopathy probably secondary to 1. Hypoxia, 2.Systemic infection; r/o Old bilateral lacunar infarction. Cranial MRI was suggested to document possible previous infarction. LMWH and anti-platelet were continued. Citicholine 1g/IV q12 was started. Outcome: – There was noticeable improvement in patient’s sensorium (GCS11 E4V1M6)

21. Course in the Wards On 6 th HD, patient had occasional spontaneous eye opening, followed some commands with pupils 2mm ERTL, and can move all extremities equally. Citicholine 500mg/cap BID was continued

22. Decreased sensorium Outcome: Resolved

23. Problem: Anemia 3/22/10

24. Course in the Wards Admission: – patient had pale palpebral conjunctivae – CBC: slightly low hemoglobin (Hgb 119) 3 rd HD – Repeat CBC: Hgb 86. – Blood transfusion with 2 ’u’ PRBC was done with strict congestion precaution. On the 4 th hospital day – Repeat CBC: normal hemoglobin

25. Course in the Wards On the 11 th HD, – repeat CBC showed Hgb of 93, patient was again transfused 1 ‘u’ PRBC and repeat CBC showed Hgb of 120. On the 14 th HD, – repeat CBC showed Hgb of 98, patient was transfused with 1 ‘u’ PRBC and repeat CBC showed Hgb of 106. On the 40 th and 44 th HD, – repeat CBC showed a decreasing trend for Hgb (116 to 101).

26. Course in the Wards On the 54 th HD, – CBC: Hgb=105 with normal platelet and WBC On the 93 rd HD, – CBC: hemoglobin of 80 – One unit of packed RBC divided to two aliquots was transfused for over twelve hours.

27. Problem: Anemia Outcome: Resolved

28. Aspiration Pneumonia 3/22/10

29. Course in the Wards Upon admission – Respiratory distress with RR of 28, febrile at 37.8  C, with bibasilar crackles – CXR: ill-defined infiltrates over both lung bases, more on the right side, which may represent pneumonic process – Patient was hooked to mechanical ventilator under AC mode, TV 350, FiO2 100%, BUR 18, P/F 60, – combivent nebulization + 2cc Ambroxol q8 were also given and Ertapenem 1g/IV OD and N-acetylcysteine 600mg/tab 1 tab OD were started – Patient was maintained on moderate to high back rest with strict aspiration precaution – Azithromycin 500mg/tab 1 tab OD was added to previous medications – Decrease in bibasilar crackles was observed but patient still had febrile episodes

30. Course in the Wards On the 4 th HD – Persistence of febrile episodes and patient developed crackles and rhonchi on both lung fields – Ertapenem was shifted to Piperacillin-Tazobactam 4.5g/IV q8 and paracetamol 500mg/tab q4 PRN for T  38.0  C was given – CXR: showed magnified cardiac size, sclerotic aortic arch, progression of pneumonic infiltrates in both lungs, bilateral pleural effusion, and osteopenia of visualized osseous structures. On the 7 th HD – Patient was still febrile and with bilateral crackles – CXR: minimal resolution of the interstitial alveolar infiltrates in both lung with slight resolution of pleural effusion bilaterally. On the 8 th HD – Persistence of febrile episodes, with crackles bilaterally, was referred to Infectious Disease service, and was started on Amikacin 700mg/IV via infusion for 2 hours, once a day for 5 days. – ET aspirate was submitted for culture and sensitivity and grams stain which revealed no microorganims seen with PMN leukocytes of 4 plus.

31. Course in the Wards – On 11 th HD – ET aspirate C & S result revealed Klebsiella pneumoniae, hence Piperacillin-Tazobactam was shifted back to Imipenem when afebrile. On the 15 th HD – Patient underwent tracheostomy. – Post-op, patient tolerated the procedure well, she was afebrile with decreased crackles on both lung fields – Repeat CBC showed normal WBC count. Imipenem was then shifted down to ciprofloxacin 500mg/tab, 1 tab BID and co-amoxyclav 625mg/tab, 1 tab BID both to be taken for 14 days. On the on the 18 th HD – CXR: progression of pleural e ffusion on the right and with hazy opacities still on right lung upper lobe. – ET aspirate GS and CS were also requested. Anitbiotics and duavent nebulation q8 were continued.

32. Course in the Wards On the 20th HD – Patient experienced difficulty in breathing and ABG was requested and showed partially compensated respiratory acidosis, mechanical ventilator set-up was then adjusted accordingly and duavent nebulization was increased to q6. On the 25 th HD – ABG: fully compensated respiratory acidosis and pneumothorax in the right hemithorax, regression of pulmonary edema, with no significant change in pleural effusion, respectively. On the 28 th HD – CXR: when compared to the one done 4/16/10 showed progressive haziness over the right lungfield, as well as the left lower lung area, there is slight reexpansion of the right upper lung area. – Antibiotics were still continued and congestion was entertained so intravenous fluids was discontinued and Furosemide 20 mg/IV was given. On the 30 th HD – Her antibiotics, which she took for 14 days were discontinued. On the 31 st HD – CXR revealed no significant interval change from the one previously done. On the 38 th HD, – ABG showed partially compensated metabolic alkalosis.

33. Course in the Wards On the 39 th HD – ABG showed fully compensated metabolic alkalosis. – CXR: partial clearing of the pneumonia opacities bilaterally, there is partial resolution of the right sided pleural effusion and the rest of the lung finding is stationary. On the 48 th and 51 st HD – ABG showed fully compensated metabolic alkalosis. On the 60 th -63th HD – the patient was tried to wean from the mech vent but the patient did not tolerate. ABG was done thrice. On the 67th HD – CXR: clearing of the pulmonary edema or pneumonia and non-specific interstitial infiltrates are seen in the right upper lung area.

34. Aspiration Pneumonia Outcome: Improvement

35. Multiple Electrolyte Abnormalities 3/22/10

36. Course in the Wards Upon admission – Na and K were requested which revealed hypokalemia (3.25mmol/L) and hypernatremia (147.15mmol/L). – Kalium durule 2 durules TID for 3 doses was then given. – Repeat Na and K was done and showed normal results. On 4 th HD – Repeat Na and K showed hypokalemia ( 2.93), KCL drip 40mEq in 80cc PNSS for 3 doses was started and Kalium durule 2 durules initially then 1 durule TID for 3 doses were given. – Repeat serum K was done the following day and showed normal potassium. On 8 th HD – Repeat Na and K showed hypokalemia (3.27), Kalium durule 2 durules initially then 1 durule TID for 3 doses were given. Repeat potassium showed normal value of 4.26 mmol/L.

37. Course in the Wards On the 21st HD – Na and K showed hypokalemia (3.61). Patient was then given Kalium durule TID for 6 doses. Repeat Na and K then showed increase in K to 3.76. On the 23 rd HD – Na and K showed hypokalemia (3.68). On the 25 th HD, K results were normal (3.98) and Kalium durule was discontinued. On the 33 rd HD – Patient was hypokalemic (3.5) Kalium durule TID, 1 durule for 6 doses was given. On the 41 st HD – Patient was assessed to have hyponatremia (125.57) probably secondary to SIADH. NaCl tab 1 tab TID was given.

38. Course in the Wards On the 45 th HD – Na (140), K (3.96), Mg (2.35), and iCa (1.15) were all normal. On the 50 th HD – Na was slightly decreased (136) and potassium was normal (4.09). On the 54 th HD, Na (137) and potassium (4.33) became normal. On the 73 rd HD – Potassium was low (2.75) and Kalium durule was started 1 dose qid x 6 doses was given. On the 74 th HD – Potassium was 3.67 and repeat potassium was 3.65. Kalium durule was discontinued. On the 85 th HD – Potassium levels was 3.05 so Kalium durule was given. On the 86 th HD – Repeat potassium showed improvement of 4.09 so Kalium durule was discontinued.

39. Course in the Wards On the 92 th HD – Potassium results showed 3.41; hence kalium durule was once again started, given for 1 day. On the 93 rd HD – Potassium and sodium was normal at 3.89 mmolo/l and 144 mmol/l On the 95 th HD – Potassium was low at 2.75 and sodium was normal at 141.03 and KCl drip was started at 40 meqs in 80 cc PNSS for 4-6 hours. Kalium durule 1 dose qid x 8 doses was given also. On the 97 th HD – Potassium was low at 3.26 and sodium was normal at 138. Kalium durule 1 durule at TID for 6 more doses was given. On the 102 nd HD – Potassium was low at 2.03 and sodium was normal at 140 and NaHCO3 was discontinued. Kalium durule at 3 durules then 2 durules QID for 6 doses was given. Kcl drip at 20 meqs in PNSS over 6 hours for 2 doses was started. On the 103 rd HD – Repeat sodium and and potassium was requested and revealed hypokalemia of 3.44 and normal sodium (137). The 1 st KCl drip was to be consumed and 2 nd dose was discontinued and kalium durule was decreased to 1 durule TID for 6 doses.

40. Multiple Electrolyte Abnormalities Outcome: Unresolved, recurring

41. Hospital Acquired Pneumonia 6/22/10

42. Course in the Wards On the 92 nd HD – Patient was noted to be febrile at 38°C and was started on clindamycin 300 mg/tab q6 and ciprofloxacin 250 mg/tab BID. On the 95 th HD – Patient had 6-7 episodes of loose bowel movement with yellowish brown stools and noted mucoid consistency but non-foul smelling and clindamycin was shifted to metronidazole 500mg/tab 1 tab q8 On the 101 st HD – There was noted decreased breath sounds on bilateral lung and chest x-ray was requested with the impression to consider pneumonia on the right lung base, minimal pleural effusion, bilateral. On the 102 nd HD – Patient was to be shifted from ciprofloxacin to cefoperazone_sulbactam 1.5 gm/IV q 8hr however was not available due to financial constraints. Ciprofloxacin 250 mg/tab 1 tab BID was then continued. On the 106 th HD – Patient would develop febrile episodes and Fluconazole and Metronidazole was started

43. Hospital Acquired Pneumonia Outcome: Unresolved