Transcript Shockingly Painful A Case Presentation

Shockingly Painful
A Case Presentation
Group 7:
Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong
December 22, 2010
Medicine Clerkship Rotation
The Medical City
General Data
CFG
58 years old
Female
Filipino
Roman Catholic
From Pasig City
Informants: Patient and sister (good reliability)
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Chief Complaint:
Abdominal pain
Morning PTA
Persistent
Abdominal pain
Post-prandial
Epigastric
30 minute duration
Crampy, 6/10 pain scale
No relief with Itopride (Ganaton)
No aggravating factors
Radiates to the back
Intermittent
No associated:
Fever, Nausea, Vomiting, Bowel movement changes
Afternoon PTA
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Chief Complaint:
Abdominal pain
Morning PTA
Abdominal pain
Persistent
Afternoon PTA
Abdominal pain
Increased intensity
Epigastric
30 minute duration
Crampy, 6/10 pain scale
No relief with Itopride (Ganaton)
No aggravating factors
Radiates to the back
Intermittent
Associated chills and undocumented fever
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Chief Complaint:
Abdominal pain
ER Consult
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Pertinent Review of Systems
•
(+) Generalized weakness
No weight gain or weight loss. Easy fatiguability
•
•No headache, seizures, blurring of vision, ear
problems
•No dyspnea, cough, colds
•No palpitations, chest pain
•No nausea, vomiting
•No dysuria, frequency
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Past Medical History
Hypertension Stage II
20 years
On Losartan + Hydrochlorothiazide
Asthma
No recent consults
Unrecalled last exacerbation
No maintenance medications
Erythromycin allergy (rashes)
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Past Medical History
s/p Laparoscopic cholecystectomy with subsequent
development of stricture, s/p biliary stent placement
(2005)
s/p Biliary stent replacement (2007)
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Family History
•
•
Hypertension
Asthma
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Personal-Social History
• Divorced
• Smoker (20 pack years)
• Occasional alcoholic drinks
• Usual diet: meat, fatty food, soda
• Occupation: Businesswoman/student
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Physical Examination
Vital Signs
General
HEENT
Chest
Abdominal
Extremities
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Physical Examination
Ht: 152 cm, Weight 68 kg,
BMI: 29.4 (overweight)
BP: 150 / 70
Temp: 39.5oC
Vital Signs
General
HEENT
Chest
HR: 88
RR: 21
Abdominal
Extremities
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Physical Examination
Conscious
Coherent
Vital Signs
General
HEENT
Alert
Not in respiratory distress
Chest
Abdominal
Extremities
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Physical Examination
Icteric sclerae
Pink palpebral conjunctiva
Vital Signs
General
HEENT
Neck veins not distended
No CLAD
Chest
Abdominal
Extremities
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Physical Examination
Symmetric chest expansion
No retractions
Vital Signs
General
HEENT
Clear breath sounds
Adynamic precordium
Chest
Abdominal
Extremities
Normal S1 and S2
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Physical Examination
Protuberant
5 bowel sounds per minute
(normoactive)
Tympanitic
No masses
Epigastric and right upper
quadrant tenderness
Vital Signs
General
HEENT
Chest
Abdominal
Extremities
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Physical Examination
Full and equal pulses
Vital Signs
General
Normal skin color
Good skin turgor
HEENT
Chest
Abdominal
Extremities
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Salient Features
58 year old female
Acute abdominal pain (epigastric)
Accompanied by chills and fever
History of cholecystectomy with biliary
stent placement and replacement (2005
and 2007)
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Admitting Impression
Acid Peptic Disease
r/o failed biliary stent
r/o viral hepatitis
r/o beginning pancreatitis
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Differential Diagnoses
Cholecystitis and biliary Liver abscess
colic
Acute appendicitis
Diverticular disease
✓ Perforated peptic ulcer
✓ Hepatitis
✓Ascending cholangitis
✓ Pancreatitis
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
✓ Hepatitis
Salient Features
+/-
Hepatitis
+
Mortality: < 5 y/o and > 50 y/o
Abdominal pain and tenderness
(epigastric) radiating to the back
+
Epigastric or RUQ pain with radiation
to back
Accompanied by chills and fever
+
Accompanied by fever
Acute onset
+
Acute onset
Icetric sclerae and not jaundiced
-
Jaundice
58 year old, female
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
✓ Pancreatitis
Salient Features
+/-
Pancreatitis
+
African-American; 35-64 y/o
Abdominal pain and tenderness
(epigastric) radiating to the back
+
Epigastric or RUQ pain with radiation
to back
Accompanied by chills and fever
+
Accompanied by fever
History of cholecystectomy with
biliary stent insertion and
replacement (2005 and 2007)
-
History of recent surgery or invasive
procedure
Acute onset
+
Acute onset
Icetric sclerae and not jaundiced
-
Jaundice
58 year old, female
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
✓ Peptic Ulcer Disease
Salient Features
+/-
Pancreatitis
58 year old, female
Abdominal pain and tenderness
(epigastric) radiating to the back
Accompanied by chills and fever
History of cholecystectomy with
biliary stent insertion and
replacement (2005 and 2007)
Acute onset
Icetric sclerae and not jaundiced
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
✓ Ascending cholangitis
Salient Features
+/-
Ascending cholangitis
58 year old, female
Abdominal pain and tenderness
(epigastric) radiating to the back
Accompanied by chills and fever
History of cholecystectomy with
biliary stent insertion and
replacement (2005 and 2007)
Acute onset
Icetric sclerae and not jaundiced
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Diagnostic Plan
Laboratory test
Rationale
Baseline values; determine presence of
CBC with differential count
infection , anemia, etc.
Electrolyte panel with renal
Assess metabolic state and kidney function
function
Liver function test
Determine possible liver pathology
(e.g. hepatitis)
Prothrombin time/ activated
Coagulapthies (e.g. DIC, cirrhosis)
partial thromboplastin time
Lipase
Usually elevated in pancreatitis
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Diagnostic Plan
Laboratory test
Rationale
Urinalysis
Baseline values; determine presence of
infection , glucose, protein, etc.
Culture and sensitivity for
blood, bile, stent
Determine foci of infection and resistance
profiles
Chest x-ray
Baseline study
Ultrasound
Visualization of the biliary tree
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Objective
Subjective
Hospital Day 1: Floors to ICU
AM: Stable at the floors
Decreased responsiveness
Restlessness
Febrile
BP: 160/90→90/60
HR: 100s
RR: 40s
O2 saturation:
97%→88%
+ Alar flaring, + Ronchi and rales
Occasional wheezing
Distended abdomen; soft, non-tender
Normal rate, regular rhythm
Distinct S1
No edema
Full and equal pulses
Flushed skin
Signs of jaundice
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Definition of terms
Septicemia
• Presence of microbes or their toxins in
blood
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Definition of terms
SIRS
• Systemic Inflammatory Response
Syndrome
•2 or more of the following:
>38oC
< 36oC
> 24 breaths
/min
> 90 beats
/min
> 12000/L
< 4000/L
WBC
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Definition of terms
Sepsis
• 2 or more of SIRS components with a
proven or suspected microbial etiology
>38oC
> 90 beats
/min
< 36oC
> 12000/L
< 4000/L
WBC
> 24 breaths
/min
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Definition of terms
Septic shock
• SIRS + hypotension
>38oC
BP: < 90
systolic
< 40 mmHg
less than
> 90 beats
/min
< 36oC
> 24 breaths
/min
patient’s normal
> 12000/L
< 4000/L
WBC
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Definition of terms
Ascending Colangitis
• Charcot’s Triad:
• Right upper quadrant pain, Fever, Jaundice
>38oC
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Acute Cholangitis
Biliary obstruction
Host antibacterial
defenses
bacteria
bacteria
Immune dysfunction
bacteria
bacteria
bacteria
bacteria
bacteria
bacteria
bacteria
bacteria
bacteria
bacteria
bacteria
bacteria
bacteria
bacteria
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, 33
Ong
Acute Cholangitis
Hepatic Ducts
Biliary Tree
bacteria
Duodenum
Portal
venous
bacteria
blood
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, 34
Ong
Septic Shock
Monocytes
Peptidoglycan
LPS
Bacteria
Host binding
protein
fimbriae
DNA
CD 14
Lipoteichoic
acid
macrophages
Neutrophils
Cytokines
leukotriens
TLR
chemokines
prostanoids
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, 35
Ong
Septic Shock
Inc. Blood flow
IL-6
Enhance vessel
permeability
Recruit neutrophils
monocytes
Endothelial
cells
Elicit pain
Coagulation!
Cytokines
leukotriens
chemokines
prostanoids
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, 36
Ong
Septic Shock
• Control Mechanisms
•Prevent inflammation within organs
distant from infection site
Work of anti-inflammatory molecules
•
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Septic Shock
• Organ dysfunction and shock
• Prevalence of anti-inflammatory
•
•
molecules
Blood leukocytes often
HYPOresponsive to agonists such
as LPS
- Increases risk of mortality
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Septic Shock
• Vascular injury
Leukokcyte-derived
mediators
Vascular
injury
Platelet-leukocytefibrin thrombi
• Endothelial injury
TNFa
Vascular endothelial cells
Procoagulant
Nitric
oxide
PAF
cytokines
molecules
SHOCK!!!
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, 39
Ong
Objective
Subjective
Hospital Day 1: Floors to ICU
AM: Stable at the floors
Decreased responsiveness
Restlessness
Febrile
BP: 160/90→90/60
HR: 100s
RR: 40s
O2 saturation:
97%→88%
+ Alar flaring, + Ronchi, rales
Occasional wheezing
Distended abdomen; soft, non-tender
Normal rate, regular rhythm
Distinct S1
No edema
Full and equal pulses
Flushed skin
Signs of jaundice
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Assessment
• Severe septic shock secondary to
ascending cholangitis
• secondary to biliary duct stricture s/p
stent replacement (2007)
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Plan
• Intubation
• Transfer to ICU
• Stat ERCP
• Antibiotics (Pip-Tazo) → Linezolid and
imipinem
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
ERCP
• Endoscopic Retrograde
Cholangiopancreatography
• Diagnosis and treatment of benign malignant
pancreaticobiliary diseases
Indications
Benefits
•
•
•
•
Gallstones trapped in main bile duct
• Diagnostic and therapeutic
Blockage of bile duct
technique (e.g. gallstones,
Jaundice
blockage)
Undiagnosed persistent, recurrent upper
• Shorter hospital stay
abdominal pain
• Unexplained loss of appetite and weight
loss
• Cancer of the bile ducts or pancreas
• Pancreatitis
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
ERCP
• Duodenoscope
• Fiber-optic duodenoscope
• Videoscope
“ERCP”. Jackson Siegelbaum. Gastroenterology.
(http://gicare.com/Endoscopy-Center/ERCP.aspx)
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Antibiotics
Linezolid and Imipenem
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Diagnostics
CBC
Urinalysis
ABG
Liver Function Tests
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Diagnostics
CBC
Hemoglobin = 132 g/dl
Hematocrit = 0.37
Platelets = 224
WBC = 14.5
Neutrophils = 0.93
Lymphocyte - 0.06
Monocyte = 0.01
ABG
pH = 7.352
pCO2 = 26.4
pO2 = 63.1
HCO3 = 15.7
BE = -7.1
O2 sat. = 91.73
Urinalysis
Color: Dark Yellow
Sp. gravity: 1.015
+ Erythrocytes, urobilinogen, bilirubin
Liver Function Tests
Hepatitis tests: non-reactive
SGOT: 542.7 U/L ↑
SGPT: 636.8 U/L ↑
Alk. Phos: 137.1 U/L ↑
Total Bilirubin: 6.17 mg/dL ↑
Direct Bilirubin: 4.02 mg/dL ↑
Indirect Bilirubin: 2.15 mg/dL ↑
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
ABG Interpretation
ABG
pH = 7.352
pCO2 = 26.4
pO2 = 63.1
HCO3 = 15.7
BE = -7.1
O2 sat. =
91.73
Acceptable
ranges:
pH: 7.35-7.45
pCO2: 35-45
HCO3: 22-26
BE: +2 to -2
• pH: Acidotic
• HCO : below normal, metabolic
3
acidosis
• pCO : below normal, respiratory
2
alkalosis
Metabolic acidosis with concomitant
respiratory alkalosis
Oxygenation: adequate
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Diagnostics
CBC
Hemoglobin = 132 g/dl
Hematocrit = 0.37
Platelets = 224
WBC = 14.5
Neutrophils = 0.93
Lymphocyte - 0.06
Monocyte = 0.01
ABG
pH = 7.352
pCO2 = 26.4
pO2 = 63.1
HCO3 = 15.7
BE = -7.1
O2 sat. = 91.73
Urinalysis
Color: Dark Yellow
Sp. gravity: 1.015
+ Erythrocytes, urobilinogen, bilirubin
Liver Function Tests
Hepatitis tests: non-reactive
SGOT: 542.7 U/L ↑
SGPT: 636.8 U/L ↑
Alk. Phos: 137.1 U/L ↑
Total Bilirubin: 6.17 mg/dL ↑
Direct Bilirubin: 4.02 mg/dL ↑
Indirect Bilirubin: 2.15 mg/dL ↑
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Liver Function Interpretation
Liver Function Tests
Hepatitis tests: non-reactive
SGOT: 542.7 U/L ↑
SGPT: 636.8 U/L ↑
Alk. Phos: 137.1 U/L ↑
Total Bilirubin: 6.17 mg/dL ↑
Direct Bilirubin: 4.02 mg/dL ↑
Indirect Bilirubin: 2.15 mg/dL
↑
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Diagnostics
ECG
Chest X-ray
Cardiac Enzymes
Cultures
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Diagnostics
ECG
Normal sinus rhythm
Leftward axis
Left atrial enlargement
Non-specific ST-T wave changes
No significant changes from 11/27/2010
Chest X-ray
Subsegmental atelectasis, right
Cardiomegaly
Atheromatous aorta
Thoracic spondylosis and dextroscoliosis
Cardiac Enzymes
Troponin T = 0.57 ng/ml
CK Total = 306.3 U/L ↑
CK MB = 23.44 U/L
CK MM = 282.9 U/L ↑
Cultures
Stent and blood
Bile
Stent
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Cardiac Enzymes
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Diagnostics
Serum Electrolytes
Other tests
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Diagnostics
Serum Electrolytes
Sodium = 139 meq/L
Potassium= 3.3 meq/L
Others
Amylase = 126 U/L ↑
Lipase = 96.56 U/L ↑
Lactate = 50.52 mg/dL ↑
Creatinine = 0.64 mg/dL ↑
NGAL = 225.2 ng/mL ↑
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Enzymes: Amylase, Lipase
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
NGAL
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Physical Examination
Hospital Day 1
•
•
CNS: GCS 11, sedation with Midazolam
CVS:
•BP: 75/40 to 150/70, tachycardic hypotensive episodes
•On dopamine and/or norepinephrine drip
•(+) Trop T, elevated CK enzymes, anterior wall ischemia on
→
ECG
•Given Enoxaparin (Clexane), 0.6 ml every 12 hours
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Drugs
Enoxaparin
• Anticoagulant
• Binds to anti-thrombin III and
accelerates activity, inhibiting thrombin
and Factor Xa (low molecular weight
heparin)
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Physical Examination
Hospital Day 1
•
Respiratory:
•Oxygen saturation = 98%
•+ Ronchi bilaterally
•+ Rales on the right base
•
IDS
•Febrile
•On Linezolid and Imipenem
•
Unremarkable GI, GU and Endocrine findings
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Acute Respiratory Failure
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Consideration for non-ST elevation
Myocardial Infarction
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Assessment
• Acute respiratory failure secondary to
septic shock secondary to ascending
cholangitis s/p ERCP
• Hypertension, to consider non-ST
elevation myocardial infarction
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Plan
• Close monitoring
• Maintain hemodynamic stability
• Administration of Linezolid and
Imipenem
• Mechanical ventilation
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Laboratory
Objective
Hospital Day 3: ICU
Cultures:
CNS: GCS 11 (E4VtM6) with episodes of
agitation
on Midazolam 5 ml/hr
Hemoglobin = 83 g/dL
Hematocrit = 0.25
Platelets = 119
WBC = 15.4
Bands = 0.02
Neutrophils = 0.85
Lymphoctes = 0.08
Monocytes = 0.04
Eosinophil = 0.01
Hypochromic
Stent and blood:
Klebsiella pneumoniae
Bile: Heavy growth of
Escherichia coli
Stent: Proteus mirabilis
*All organisms sensitive to
Ceftriaxone and ampicillin
•Serum Creatinine = 1.68 ↑
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Antibiotics
Ceftriaxone and Ampicillin
• Culture guided antibiotics
• Mechanism of action...
• Coverage...
• For Mimi
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Acute Kidney Injury
• Sublethal injury to tubular and other
renal cells
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Anemia
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Assessment
• Acute Respiratory Failure secondary to
Septic shock secondary to ascending
cholangitis s/p ERCP
• Hypertension t/c non-ST elevation MI
• Acute kidney injury
• Anemia probably secondary to upper GI
bleed
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Plan
•
•
•
•
•
•
Close monitoring
For blood transfusion
Ulcer prophylaxis
Potassium correction
For step-down antibiotics - Ceftriaxone and
ampicillin (culture guided)
Possible mechanical ventilation weaning
(extubation on hospital day 6)
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Hospital course
•
Day 5: extubated, well-tolerated
•
Day 6: transfer to the floors
•
Day 11: discharged
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Principles of Management
Septic Shock
• Close monitoring (vital signs, I/O)
• Hemodynamic support with IV fluids
and vasopressors
• Identify underlying cause for sepsis
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Principles of Management
Ascending Cholangitis
• ABC assessment
• IV fluid resuscitation with crystalloids
(e.g. plain NSS)
• Parenteral antibiotics
• Biliary decompression (severe cases)
• Extracorporeal shockwave lithotripsy
(ESWL) for choleliths
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Acute Cholangitis
Severe
Mild
Monitor with reassessment
Improvement
ICU
ERCP
No improvement
Elective ERCP
with definitive therapy
of bile duct stones
within 24-48 hrs
Source: http://emedicine.medscape.com/article/774245-media
Improvement
Elective ERCP
with definitive therapy
(if not previously done)
No improvement
Percutaneous drainage
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Ascending Cholangitis
Prognosis
•
•
•
Depends on the following:
•Early recognition and treatment of cholangitis
•Response to therapy
•Underlying medical conditions of the patient
Mortality rate: 5-10% (higher in patients who
require emergency decompression or surgery)
Good response to antibiotics = good prognosis
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Ascending Cholangitis
Complications
•
•
•
Liver failure, hepatic abscess, microabscess
Acute renal failure
Bactermia, sepsis (gram-negative)
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Septic Shock
Prognosis
•
•
Depends on the following:
•Severity of illness
•Co-morbidities
•Age
Response to antibiotics
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Septic Shock
Complications
•
•
•
•
•
Acute respiratory distress syndrome (ARDS)
Renal dysfunction
Disseminated intravascular coagulation (DIC)
Mesenteric ischemia
Myocardial ischemia and dysfunction
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Preventable
gallstones?
2004
5 million Filipinos with gallstones
2010
5.4 Filipinos estimated to have gallstones
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Risk Factors
Diet
Medications
Obesity
Weight cycling
Smoking
Genetics
Sedentary lifestyle
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Risk Factors
More trans fat
High glycemic index
> 36 inches
Increased risk
Arch Intern Med. 2005 May 9;165(9):1011-5
Am J Clin Nutr. 2008 Mar;87(3):627-37
2x risk for cholecystectomy
Gut. 2006 May; 55(5): 708-14
15/1000 smokers
Sedentary lifestyle
Increased risk
Am J Epidemiol. 2009 Jan 15;169(2):153-60
Increased
risk
Ann Intern Med. 1998 Mar 15;128(6):417-25.
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
call-an-jee-tis
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Role of Practitioners
Policy
Stop trans fat use
Surveillance of harmful dietary
substances
Education at the school level
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Healthcare
Availability
12 days
x
Php 44,000 / day
Php 488,000
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
How many Filipinos can
afford the same healthcare?
? that!
Fewer50%
10%
30%
5%
than
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Facts
Earns:
Spends:
Savings:
Php 206,000
Php 176,000
Php 30,000
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Facts
16 years to pay
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Average income
Number of
families
Average income
per bracket
Average
expenditure per
bracket
P250,000 and above
3,264,000
471,000
361,000
P100,000 – P249,999
6,271,000
157,000
143,000
P60,000 – P99,999
4,122,000
79,000
77,000
P40,000 – P59,000
2,355,000
50,000
52,000
P40,000 and below
1,392,000
30,000
33,000
Total families: 17,403,000 (2006)
http://www.census.gov.ph/data/sectordata/2006/fies0608r.htm
http://www.census.gov.ph/data/sectordata/2006/fies0602r.htm
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
PhilHealth
Case B
Hospital discount: Php 33,600
Private Tertiary Hospital
Php 488,000 to 454,400
Government/Public Tertiary hospital
1/3 of private costs: Php 162,000
The PhilHealth Member would pay only Php 128,400
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Shockingly Painful
A Case Presentation
Group 7:
Asuncion, Dalman, Doromal, Dy, Generoso, Mejia, Ong
December 22, 2010
Medicine Clerkship Rotation
The Medical City