Transcript ICU Case Presentation

G7 Grand Rounds
Asuncion * Dalman * Doromal * Dy
Generoso * Mejia * Ong
Internal Medicine Rotation- The Medical City
December 22, 2010
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Identifying Data
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CFG, 58 y/o
Filipino female
Roman Catholic
From Pasig
Informants: Patient and sister (good reliability)
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Chief Complaint
• Epigastric pain
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History of Present Illness
Morning PTA
• Post-prandial epigastric pain (6/10)  crampy,
intermittent, 30 minute duration, with radiation to the
back
• Took Itopride (Ganaton)  no relief
• (-) fever, nausea, vomiting, changes in bowel
movement
Afternoon PTA
• Epigastric pain with increased intensity; (+) chills and
fever
• Consult at TMC-ER  admission
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Review of Systems
• (+) generalized weakness
• No weight gain or weight loss, easy fatigability
• No headache, seizures, blurring of vision, ear
problems
• No dyspnea, cough, colds
• No Palpitations, chest pain
• No nausea, vomiting
• No dysuria, frequency
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Past Medical History
• (+) Hypertension – 20 years
• S/p laparoscopic cholecystectomy with
subsequent development of stricture, s/p
stent placement (2005)
• S/p biliary stent replacement (2007)
• Allergic to erythromycin – rashes
Past Medical History
• Hypertension
– 20 years
– On Losartan + Hydrochlorohiazide
• Asthma
– No recent consults
– Last attack unrecalled
– No maintenance medications
Family History
• Hypertension
• Asthma
Personal and Social History
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Divorced
Smoker
Occasional alcohol beverage drinker
Usual diet: prefers meat and fatty food, soda
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Physical Exam
• Anthropometrics: Height=152 cm, weight=68 kg,
BMI=29.4 (overweight)
• Vitals: BP: 150/90, T: 39.5oC, RR 21, HR 88
• General: conscious, coherent, alert
• HEENT: anicteric sclerae, pink palpebral conjunctiva,
neck veins non-distended, no
cervicolymphadenopathies
• Chest: Symmetric chest expansion, no retractions ,
clear breath sounds
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Physical Exam
 Abdomen: Protuberant, normoactive, tympanitic, no
masses palpated, epigastric and right upper
quadrant direct tenderness
 Extremities: Full and equal pulses, good skin color
and turgor
 Digital rectal exam:
Salient Features
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58 year old, female
Acute abdominal pain (epigastric, RUQ areas)
Accompanied by chills and fever
History of cholecystectomy with biliary stent
insertion and replacement (2005 and 2007)
Ascending cholangitis
ASSESSMENT
Differential Diagnosis
• Cholecystitis and biliary
colic
• Diverticular disease
• Hepatitis
• Mesenteric ischemia
• Pancreatitis
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Cirrhosis
Liver failure
Liver abscess
Acute appendicitis
Perforated peptic ulcer
Pyelonephritis
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Hepatitis
Salient Features
58 year old, female
+/+
Pancreatitis
Mortality: < 5 y/o and
>50 y/o
Abdominal pain and
tenderness (epigastric, RUQ
areas) radiating to the back
+
Epigastric or RUQ pain
with radiation to back
Accompanied by chills and
fever
Acute onset
Icteric sclerae and jaundiced
+
Accompanied by fever
+
+
Acute onset
Jaundice
Pancreatitis
Salient Features
58 year old, female
+/+
Pancreatitis
African- American;
35-64 y/o
Abdominal pain and
tenderness (epigastric, RUQ
areas) radiating to the back
+
Epigastric or RUQ pain
with radiation to back
Accompanied by chills and
fever
History of cholecystectomy
with biliary stent insertion and
replacement (2005 and 2007)
Acute onset
Icteric sclerae and jaundiced
+
Accompanied by fever
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History of recent
surgery or invasive
procedure
Acute onset
Mild jaundice
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Peptic Ulcer Disease
Salient Features
58 year old, female
Abdominal pain and
tenderness (epigastric, RUQ
areas) radiating to the back
Accompanied by chills and
fever
History of cholecystectomy
with biliary stent insertion and
replacement (2005 and 2007)
Acute onset
Icteric sclerae and jaundiced
+/-
Peptic Ulcer Disease
Diagnostic Plan (1 of 2)
Laboratory Test
CBC with differential
count
Electrolyte panel with
renal function
Liver function test
Rationale
Baseline values; determine
presence of infection, anemia, etc.
Assess metabolic state and kidney
function
Determine possible liver pathology
(e.g. hepatitis)
Coagulopathies (e.g. DIC, cirrhosis)
Prothrombin
time/activated partial
thromboplastin time
Lipase
Usually elevated in pancreatitis
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Diagnostic Plan (2 of 2)
Laboratory Test
Urinalysis
Rationale
Baseline values; determine
presence of infection, glucose,
protein, etc.
Culture and sensitivity Determine foci of infection and
for blood, bile, stent resistance profiles
Chest x-ray
Baseline study
Ultrasound
Visualization of the biliary tree
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COURSE IN THE WARDS
Hospital Day 1: Floors to ICU
Subjective
Objective
Assessment
Plan
• Stable at the
floors early in
the AM
• Decreased
responsiveness
• Restlessness
BP: 160/60 90/60
HR: 100s
RR: 40s
O2 sat’n: 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
Severe septic shock
secondary to
ascending
cholangitis
secondary to biliary
duct stricture s/p
stent placement
• Intubation
• Transfer to ICU
• Stat ERCP
• Antibiotics (PipTazo  Linezolid
and Imipenem)
Hypertension
Hospital Day 1 – Diagnostics
CBC
Hemoglobin = 132 g/dL
Hematocrit = 0.37
Platelets = 224
WBC = 14.5
Neutrophils = 0.93
Lymphocytes = 0.06
Monocyte = 0.01
ABG
pH = 7.382
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
Others
Hepatitis tests: non-reactive
SGOT: 542.7 U/L ↑
SGPT: 636.8 U/L ↑
Alk Phos: 137.1 U/L ↑
Amylase: 126 U/L
Lipase: 96.56
Potassium: 3.3 mmol/L
Hospital Day 1 – 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
Cultures
Stent and blood: Klebsiella pneumoniae
Bile: Heavy growth of Escherichia coli
Stent: Proteus mirabilis
* All orgnisms sensitive to Ceftriaxone
Principles of Management
Septic Shock
• Close monitoring
(vital signs, I/O)
• Hemodynamic
support with IV
fluids and
vasopressors
• Identify underlying
cause for sepsis
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
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Source: http://emedicine.medscape.com/article/774245-media
Looking Ahead – 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
Complications
• Liver failure, hepatic
abscess, microabscess
• Acute renal failure
• Bacteremia, sepsis (gramnegative)
Looking Ahead – Septic Shock
Prognosis
• Depends on the following:
– Severity of illness
– Co-morbidities
– Age
• Response to antibiotics
Complications
• Acute respiratory distress
syndrome (ARDS)
• Renal dysfunction
• Disseminated intravascular
coagulation (DIC)
• Mesenteric ischemia
• Myocardial ischemia and
dysfunction
Other Aspects of the Case
Psycho-socio-economic
Impact
• P100,000 per day with ICU
admissions  current
expense for the patient is
around P400,000
• On patient’s personal
account
Prevention and Public Health
• Lifestyle and health-seeking
behavior changes (e.g. lowfat diet, quit smoking, stentremoval)
• Patient education
G7 Grand Rounds
Asuncion * Dalman * Doromal * Dy
Generoso * Mejia * Ong
Internal Medicine Rotation- The Medical City
December 22, 2010
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