1. Mortality Audit: ER FEBRUARY 2015 Dominguez, Regine P. 2 nd year resident

2. General Information VAA 14 year old Male Date of admission: 2/23/15 Chief complaint: difficulty of breathing

3. History of Present Illness 1 week prior to admission (+) Carbuncle noted over the scalp (-) fever, ear discharge, headache and vomiting 3 days prior to admission (+) Fever Tmax 39, relieved by Paracetamol (-) vomiting (+) abdominal pain, dull not associated with food intake

4. History of Present Illness 3 days prior to admission (+)consult at Calalang General Hospital CBC: Hgb 135, hct 0.41, WBC 11.8, PMN 90, LYM 10 PLT 290, UA:amber, turbid, pH 6.5, sg 1.020, protein 3+, sugar 3+, WBC 10-20, RBC 3-6, given Co-amoxiclav 1 day prior to admission (+) fever, Last fever episode 4 pm (+) epigastric pain (+) difficulty of breathing

5. History of Present Illness 1 day prior to admission (+)consult at San Jose Maternity Polyclinic CBC: Hgb 137, hct 0.41, WBC 7.7, PMN 89, LYM 9 PLT 161, UA:yellow, slightly hazy, pH 5.0, sg 1.030, protein -, sugar 2+, WBC 1-3, RBC 6-8, given Cefalexin Patient went home after consult. At home, (+) rashes over upper and lower extremities At 3 PM: Patient was brought back to SJMP. At clinic, (+) tachypnea, and wheezing

6. History of Present Illness 1 day prior to admission (+)given Hydrocortisone, Diphenhydramine, Cefuroxime (100) for three doses, Salbutamol + Ipratropium nebulization done q4 Despite medication, noted to be tachypneic. Family was advised transfer. Prior to transfer: BP 80/50, HR 160, RR 40 O2 sat 85- 99%, conscious, speaks in phrases, warm extremities (+) one episode of hematemesis

7. Review of systems (-) urinary and bowel symptoms (-) jaundice (-) edema (-) weight loss

8. Past Medical History Primary Koch Infection at 3 months of life, treated for 6 months (-) Previous hospitalization (-) Allergies to food and medication

9. Family History (+) Hypertension, Bronchial Asthma – Maternal (+) Thyroid disease - Paternal 41 year old Government employee 38 year old Government employee

10. Birth and Maternal History Born to a 24 year old G3P2 (2012) with regular prenatal check-up starting 3 months AOG at Valenzuela General Hospital, with intake of multivitamins, FeSO4, folic acid, Ultrasound : normal; (-)Urinary Tract Infection, Upper respiratory tract infection Delivered full term via normal spontaneous delivery by an OB at Valenzuela General hospital, good cry and activity, BW 3.1 kg (-) Newborn screening, (-) Hearing screening

11. Nutritional History Breastfed until 3 months Milk feeding Complimentary feeding started at 6 months

12. Developmental History Social smile – 2 months Laughs out loud – 4 months Creeps and crawls – 7 months 2 syllables- 1 year Sits alone – 1 year Walks with support – 1 year

13. Personal Social History 8 household members One level house Well lit, well ventilated Drinking water – Mineral water Garbage collection – 3 times in one week No exposure to second hand smoke No nearby factories

14. HEADSS H: Lives with both parents, good familial relationship E: Grade 8 student, with average grades A: Loves to play basketball D: Denies illicit drug use, tried drinking alcohol S: Denies sexual activity, no girlfriend S: Goes to church, Prays at night

15. Physical Examination at the ER Awake in cardiorespiratory distress BP 60 palpatory, HR 170s, RR 60s, T 36.8, 02 sat 94 Flushed skin Anicteric sclera, pink palpebral conjunctiva, (+) alar flaring Symmetric chest expansion, subcostal and intercostal retractions, (+) crackles bilateral lung fields Adynamic precordium, tachycardic, regular rhythm Globular abdomen, (-) hepatomegaly, tender epigastric pain Fair pulse

16. SubjectiveObjectiveAssessmentManagement cardiorespiratory distress BP 60 palpatory, HR 170s, RR 60s, T 36.8, 02 sat 94 Flushed skin, (+) alar flaring, Symmetric chest expansion, subcostal retractions, (+) crackles bilateral lung fields Adynamic precordium, tachycardic, regular rhythm Globular abdomen, (-) hepatomegaly, tender epigastric pain Fair pulse CBC: Hgb 144, Hct 43, WBC 11.5, 62, PMN 42, lym 35 ABG: pH 7.25, pco2 32, po2 129, hco3 14, be -12.1, so2 98 Hgt 44 Na 126, K 4.7, Cl 88, Ca 2.06 TB 3.15, DB 2.0, IB 1.11 ALT 68, AST 105, BUN 20.8, Crea 253 Septic shockStereofundin 20 cc/kg Voluven 20 cc/kg Standby intubation Refer to ICU Insert IFC D10W Start Meropenem, Vancomycin

18. SubjectiveObjectiveAssessmentManagement After Stereofundin and Voluven BP 100/60, CR 170s, CRT > 3 seconds Profuse bleeding per Endotracheal tube noted Dengue blot: Negative Postintubation ABG: pH 6.81, pcO2 74, pO2 81, SO2 79, BE -22.6 Septic shock Pneumonia very severe Rule out dengue shock syndrome Voluven at 10cc/kg for 1 hour Intubate at ET size 7 level 13 Norepinephrine 0.3 Transfuse 2 u pRBC Vitamin K

19. SubjectiveObjectiveAssessmentManagement 2 nd hour of ER stay BP 0, CR 0 BP 110/80, HR 130s, pupils 3-6 mm slowly reactive to light Septic shock, Pneumonia, very severe High quality CPR Discontinue NE Give Epinephrine 2 doses Start Epinephrine drip

20. SubjectiveObjectiveAssessmentManagement 3 rd hour of hospital stay Profuse bleeding per ET and anterior nares BP 0, CR 0 6 episodes of cardiac arrest noted 5:18 PM, CR 160s 5:55 PM BP 0, CR 0 CR 160s 6:13 PM BP 0, CR 0 High Quality CPR Epinephrine 0.1 CPR 4 minutes, Stereofundin 20cc/kg CPR 2 minutes, Stereofundin 20 cc/kg CPR 4 minutes, Stereofundin 20

21. SubjectiveObjectiveAssessmentManagement 6:45 PM BP 0, CR 0 HR 150s 7: 13 PM BP 0, CR 0 7:30 BP 0, CR 0 CPR for 4 minutes Stereofundin at 20 cc/kg CPR DNR, DNI status

22. Mortality Diagnosis Septic shock, Multiple Organ Dysfunction (Acute kidney Injury, Acute Respiratory Failure, Acute liver injury) Pneumonia, very severe Rule out Dengue shock syndrome