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
+/-
Peptic Ulcer Disease
58 year old, female
+
Tends to occur later in life
Abdominal pain and tenderness
(epigastric) radiating to the back
+
Epigastric pain
Accompanied by chills and fever
+/-
Not usually associated with chills and
fever
History of cholecystectomy with
biliary stent insertion and
replacement (2005 and 2007)
-
Not significant
+/-
Recurrent unless perforation occus
Acute onset
Icetric sclerae and not jaundiced
Usually normal PE findings
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
✓ Ascending cholangitis
Salient Features
+/-
Ascending cholangitis
58 year old, female
+
No age or sex prediliction
Abdominal pain and tenderness
(epigastric) radiating to the back
+
Presents as abdominal pain
Accompanied by chills and fever
+
Patient was febrile
+
Associated with biliary tract
manipulation
+
+/-
Acute onset
History of cholecystectomy with
biliary stent insertion and
replacement (2005 and 2007)
Acute onset
Icetric sclerae and not jaundiced
Presents with jaunice
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
↑
• Inflammation or damage to
hepatocytes
• Usually due to biliary
obstruction in the occurrence
of abdominal pain
• Elevated alkaline
phosphatase  cholestasis
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
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
• Slightly elevated amylase and lipase
levels
• Not definitive for pancreatitis (requiring
three-fold increase)
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Neutrophil Gelatinase-associated
Lipocalin (NGAL)
• Biomarker for acute ischemic renal
injury
• Expressed by neutrophils and other
epithelia (e.g. renal proximal tubules)
• Measured in urine or serum
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
• Syndrome of failure in one or both gas
exchange functions (oxygenation and/or
carbon dioxide elimination)
• PaO2 < 60mmHg (type 1) or PaCO2 >
50mmHg (type 2)
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
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 (↑ from 0.6)
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
• Broad spectrum of sublethal injury to
tubular and other renal cells
• Occurs in 1% to 25% of ICU patients
• Cause ICU of mortality (Hoise et al.)
 RIFLE F  26.3% mortality
 RIFLE I  11.4% mortality
 RIFLE R  8.8% mortality
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Acute Kidney Injury – Rifle Criteria
Grandrounds: Shockingly Painful
Group 7: Asuncion, Dalman, Doromal, Dy, Generoso, Mejia,
Ong
Anemia
• Deficiency in red blood cells,
hemoglobin, or in total volume
• Gastrointestinal bleeds: manifest as
melena, hematochezia, hematemesis
• Most common etiologies: ulcers (3159%), varices (7-20%), Mallory-Weiss
tears (4-8%)
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
• 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 4: creatinine at 0.67
•
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