1. MUNEZ

2. 3 months PTA, patient had fever, cough and colds. Consult done at a local health center where she was given amoxicillin for 1 week with noted resolution of symptoms. However, after 1 week, there was recurrence of fever, for which she was given co-amoxyclav. There was note of a palpable abdominal mass at this time.

3. 2 months PTA, (+) recurrence of fever, consult done at local health center, given cotrimoxazole with relief of symptoms. 1 ½ months PTA, (+) recurrence of fever, given cefuroxime for 2 days. Patient then had abdominal pain, gradual abdominal enlargement,(+) inguinal mass on the right. Consult done at local health center, given cloxacillin with no resolution 3 days PTA, (+) difficulty of breathing associated with on and off fever -> consult

4. Review of systems (+) weight loss (+) anorexia (+) easy fatigability (+) abdominal enlargement (+) constipation

5. Physical Exam on Admission Awake, in cardiorespiratory distress BP 90/60 HR 152 RR 40 T 38 Wt 10.8 kg pale conjunctivae, anicteric sclerae, (+)multiple cervical lymphadenopathy Equal chest expansion, (+) crackles, bilateral, decreased breath sounds, right lower lung field Globular abdomen, liver edge 10 cm below right costal margin (+) 6x7 mass on L flank, (+) multiple inguinal mass, R full pulses, (+) edema, (-) cyanosis (-) clubbing

6. Initial CXR: pneumonia, pleural effusion, right

7. Initial Assessment Pleural effusion, probably – parapneumonic process – PTB – Malignancy Intraabdominal mass, probably -Wilm’s tumor -Neuroblastoma -GI TIB Rule Out Disseminated TB

8. First thoracentesis Thoracentesis revealed an exudative pleural effusion 300 cc yellow, slightly cloudy, RBC 2700 WBC 987 PMN 1% Ly 99% Pleural FluidSerum Glucose6.125.28 Total Protein48.5252 LDH293412

9. Bacterial cultures and AFB smears were negative. Histopathologic findings showed negative for malignant cells. Antibiotics started were cefuroxime and amikacin.

10. Post thoracentesis, chest xray showed decreased pleural effusion. CTT insertion was done and removed after 3 days

11. CT scan showed extensive mediastinal and intraabdominal lymphadenopathy, hepatosplenomegaly and pulmonary nodules.

12. Patient was referred back on the 19 th day of admission. Awake, in mild respiratory distress, RR 45 HR 120 Pink conjunctivae, anicteric sclerae, multiple lymphadenopathies Equal chest expansion, (+) crackles, bilateral, decreased breath sounds, right

13. Chest xray showed increasing infiltrates with recurrence of pleural effusion, Right

14. Assessment: Recurrent pleural effusion, right probably nosocomial pneumonia vs lymphoma Repeat thoracentesis was done aspirating 550 cc of light yellow, purulent fluid

15. Second thoracentesis Thoracentesis revealed an exudative pleural effusion reddish orange, hazy, RBC 12,750, WBC 4,480 Pleural FluidSerum Glucose7.484.64 Total Protein20450 LDH29.72222

16. Repeat CXR showed decreased pleural effusion, expanded right lung Antibiotics shifted to Vancomycin and Meropenem CTT insertion was done on the right On the 5 th day after CTT insertion, patient was referred for difficulty of breathing and was intubated. CXR showed fluid accumulation on the left CTT insertion was done on the left

17. Patient was extubated after 10 days. Work up was facilitated for possible immunodeficiency. 1 week prior to demise, patient again started having episodes of fever, with growth of klebsiella on urine culture 3 days prior to demise, patient was seen drowsy to irritable 2 days prior to demise, patient was noted with increasing severity of difficulty of breathing.

18. CBC showed increased WBC count at 31.11 with neutrophils 77%. 2 days prior to demise, patient was noted tachypneic at 50s, febrile 39.8. ABG at 10 lpm showed uncorrected hypoxemia 7.465/42.3/61.4 Patient was intubated and hooked to MV 100% 8 ccc/kg Peep 5 RR 20

19. Ciprofloxacin started and Amphotericin B ordered. Day prior to demise, patient was seen with poor sensorium, harsh breath sounds on all lung fields.

20. Patient had progressively increasing respiraotry distress ABG on 100% TV 9.3 cc/kg 20 5 7.399/45.7/63.5100% TV 9.3 cc/kg 20 5 7.167/57.2/76.6100% 11 cc/kg 20 7 7.142/62.6/62.1 100% 11 cc/kg 30 7

21. PCOD: Septic shock