General Data

• L.M.• 4 year old• Male• Occidental Mindoro• 1st admission• DOA: 9/14/13• DOD: 10/2/13• Chief Complain: difficulty of breathing

History of Present Illness

3 yrs PTA

• recurrent cough: pneumonia (3-4x/year)• Intermittent fever, undesired weight loss• Unrecalled antibiotics

10 days PTA

• New onset of cough and colds, low grade fever

8 days PTA

• Still with cough, now with difficulty of breathing• PMD: CXR: pneumonia, ? Mass hence advised admission• IV meds: cefuroxime, oxacillin, metronidazole

History of Present Illness

1 day PTA

• Still with the above symptoms• PCMC: TB work up, chest CT scan

DOC

• Still with cough• Increased DOB• ER consult

Review of Systems

• Cutaneous: no rashes, no pigmentation, no pruritus, • HEENT: no lacrimation, no ear discharge, no epistaxis,

blurring of vision, no bleeding gums• Cardiovascular: no cyanosis, no palpitation • Gastrointestinal: no diarrhea/constipation, no vomiting• Genito-urinary: no frequency, no dysuria, intermittent

hematuria, amenorrheic • Hematopoietic: no easy bruisability, pallor, bleeding• Neurologic: no loss of consciousness, change in

sensorium, seizures

Birth and Maternal History

• Born to a 29yo, primigravid, non smoker, non alcoholic beverage drinker, non HPN, non DM.

• PNCU at a local hospital since 5mos AOG by and OB-GYNE• No maternal illness/exposure to viral

exanthem/radiation/illicit drug use. UTZ done twice (7th and 9th mo AOG) both normal

• Delivered FT via NSD at a local hospital assisted by an MD• Unrecalled BW, good cry and activity. No MSAF, no cord

coil, no cyanosis, no jaundice.• Given Vit K, initial doses of BCG and Hepa B upon birth• NBS and HS not done

Feeding History

• Never breastfed• MF: Bonna 1:3• CF: 8 months• Not a picky eater

Immunization

• BCG x 1• DPT x 3• OPV x 3• Hep B x 3• Measles x 1• No Hib

Growth and Developmental History

• at par with age

Past Medical History

• No previous illnesses• No hospitalizations• No surgeries• No asthma/allergies

Family History

45, fish pond caretaker

34, housewife

(+) PTB – father when patient is 9mos old (completed 6mos therapy)

2yo 3mos

Personal and Social History

• Lives at a bungalow type house, well lit and ventilated

• 6 household members• Drinking water: mineral• Garbage collected 2x/week• No pets• No exposure to cigarette• No nearby factories/radiation• No history of travel

Physical Examination

• Awake, alert, tachypneic• BP: 80/50, CR: 100, RR: 69, Temp 37, SO2: 98% RA• Pink palpebral conjunctiva, anicteric sclera, no nasoaural

discharge• Supple neck, (+) multiple CLADs• SCE, (+) subcostal retractions, good air entry, decreased breath

sounds, (+) crackles BLF, (-) wheezes • Adynamic precordium, normal rate, regular rhythm, no

murmurs• Flat abdomen, normoactive bowel sounds, soft, non tender, no

masses, no organomegaly• Full pulses, CRT < 2secs, no cyanosis, no clubbing

Admitting Impression

• Pulmonary tuberculosis• Pneumonia with consolidation

9/14/131HDConscious, coherent in respiratory distressBP: 80/50, CR: 100, RR: 69, afebrile, SO2: 98% RA(+) multiple CLADsSCE, (+) subcostal retractions, good air entry, decreased breath sounds, (+) crackles BLF, (-) wheezes

UA: unremarkable

CXRChest CT scan w/ contrast

DATParacetamolSalb q6D5LR (mtn)

Hgb 107

Plt 545

Hct 33

Seg 69

Wbc 19.7

Lym 18

Na 143 K 4

Cl 100 Ca 2.37

Ph 7.38

Pco2 36

Po2 150

So2 99

Hco3 21.3

Beb -3.3

PTT 31.5

29.9

PT 12.2

11.6

89.46

1.05

Initial Reading: TB with necrosis, endometrial TB bilateral

9/15/132nd HD

3:45amAwakeRR: 40s(+) SC retractions, (+) crackles, (+) wheezes

GAFB day 1: (-)

TAGS: few gram neg bacilliTracheal aspirate AFB: neg*TB PCR

Inc Salb q4

Referred to: Pulmo, PIDS, Ophtha (baseline)

Isoniazid (10)Rifampicin (15)Pyrazinamide (15)Ethambutol

Pulmo:A> mediastinal mass w/ cavitation and calcification, t/c PTB r/o malignancy

PIDS:Ceftriaxone (100)TB workup, screen family members

9/15/132nd HD

8:30amAwake, in respiratory distressRR: 70s(+) deep retractions, (+) crackles, (+) wheezes

ALT: 20LDH: 817AFP: 0.58BHCG: 0.10

Intubated (size 5, level 15)NPOD5LR (mild)Refer to: ICU, Hema

RICU:A> t/c cavitary TB vs malignancy

Hema Onco:A> t/c endobronchial TB vs disseminated TB

Na 138 K 4.3

Cl 84 Ca 2.21

Ph 7.29

Pco2 50

Po2 186

So2 100

Hco3 24

Beb -3

9/15/132nd HD

12pm CR 130 O2sat 100%(+) crackles BLF

post intubation

CPAP 93%

post hypervent

Pulmo: suggest CPAPCPAP @93%

Hyperventilate

Referred to TCVS:A> pneumonia w/ lung abscess, right; no mediastinal mass; middle lobe syndrome

Ph 7.33

Pco2 51

Po2 196

So2 100

Hco3 26.9

Beb 0.30

Ph 7.51

Pco2 36

Po2 174

So2 100

Hco3 29.8

Beb 5.5

Ph 7.4

Pco2 36

Po2 142

So2 99

Hco3 29.9

Beb 3.7

9/16/133rd HD

Awake, comfortableMild SC retractions(+) crackles BLF

1:46pm(+) alar flaringRR 60Increased, deep SC retractions(+) crackles BLF

NPOD5LR (mild)CPAP 93% 86%Ceftri D1t/s HRZE

Hook back to CAB

TCVS: Continue medical management

Pulmo:A> t/c Endobronchial TB vs malignancyP> possible CT guided percutaneous lung aspiration

Ph 7.30 Pco2 46

Po2 130

So2 99

Hco3 22.6

Beb -3.9

9/16/133rd HD4:05pmintubatedawake, not in distressCR 120 RR 32 TC 37

8:20pmafebrile(+) UREB, stiffening of both extremities for 1-2mins

HGT 183mg/dL

s/p Hyperventilation

*Start Clindamycin q6hrs

A> r/o TB meningitis

Referred to Neurology

A> Acute symptomatic seizure sec to metabolic hypercapnia and hypoxemia

For CT scan with contrast CSF analysis

pH7.19

pO262

PO2211

O2sat100

HCO323.7

Beb-5.3

pH7.44

PO246

PO2321

O2sat100

HCO331.2

Beb6.10

9/17/134th HDAwake, comfortableHR 100 RR 30 T37SLE (+) crackles BLF

TACS: (+) growth of Pseudomonas sp.

CABBlenderized NGT feedingCefti D2HRZE D1Clinda +1

d/c Ceftriazonet/s Ceftazidime

Ph 7.35

Pco2 68

Po2 264

So2 100

Hco3 37.5

Beb 9.4

9/18/135thHD7amAwake, not in distressNo recurrence of seizures

post BT

D5NSS (mtn)CABSalb q6, Nac q4Ceftaz +1Clinda D1+1HRZE D2

1u PRB

Pulmo:P> for UTZ guided biopsy

Hgb 86

Plt 434

Hct 27

Seg 75

Wbc 16

Lym 16

Ph 7.35

Pco2 66

Po2 215

So2 100

Hco3 28.1

Beb 6.4

Hgb 129

Plt 360

Hct 39

Seg 76

Wbc 25

Lym 10

9/19/136th HD6:30am

intubatedAwake, afebrileRR 40s(-) alar flaring(+) bilateral crackles(-) wheezes

(+) coffee ground/NGT

Ceftaz D1Clinda D2HRZE D3Ph

7.30Pco2 63

Po2 134

So2 99

Hco3 31

Beb 3

PTT 31.7

29.4

PT 12.7

11.6

82.6

1.1

9/20/137th HD

Awake, afebrileRR 42(-) alar flaring(+) bilateral crackles(-) wheezes

HyperventilatePh 7.28

Pco2 47

Po2 222

So2 100

Hco3 21.1

Beb -4.8

9/21/13

Ward:

Awake, afeb(+) good air entry, (+) bilat crackles

BCS: negative

CAB CPAPd/c NacContinue salb neb

Ph 7.38

Pco2 42

Po2 184

So2 100

Hco3 24.8

Beb -0.4

9/22/13

Awake, comfortableafebrile(-) alar flaringGood air entry(+) bilat crackles

Post MV

Post RR 25

Post PIP/PEEP

For mech vent

MV: Fio2 100% TV: 6cc RR 20 PEEP: 6-7

Inc RR to 25

PIP 15PEEP 6

Ph 7.34

Pco2 72

Po2 54

So2 86

Hco3 38.8

Beb 10.3

Ph 7.39

Pco275

Po2 181

So2 100

Hco3 45.4

Beb 16.8

Ph 7.28

Pco2 68

Po2 249

So2 100

Hco3 32

Beb 13.4

Ph 7.37

Pco2 67

Po2 311

So2 100

Hco3 38.7

Beb 10.9

9/23/13

Awake, comfortableafebrile(-) alar flaringGood air entry(+) bilat crackles

BUN <0.7Crea 22 post set up

post RR/Fio2 setup

MV: Fio2 40% RR 25 PIP: 22/6KCL incorp (KIR 0.23)Albumin tranfusionPRNC transfusion

Inc PIP 25/6

Inc RR 30Inc Fio2 100% (to dec fio2 by 10% every hr to reach 60%)

at FiO2 70% RR30

Hgb 92

Plt 394

Hct 29

Seg 72

Wbc 9.4

Lym 18

Ph 7.44

Pco256

Po2 262

So2 100

Hco3 38

Beb 11.7

Ph 7.47

Pco2 56

Po2 59

So2 92

Hco3 41.5

Beb 15.3

Ph 7.37

Pco2 67

Po2 311

So2 100

Hco3 38.7

Beb 10.9

Na 146

K 2.2

Cl 95 Ca 1.90

TP 61.7

Alb 21.2

Glob 40.6

A/G 0.50

Ph 7.37

Pco2 67

Po2 311

So2 100

Hco3 38.7

Beb 10.9

9/24/13

Awake, comfortable, NICRD afebrile(-) alar flaringGood air entry(+) bilat crackles

Post BT

d/c KCL incorporationD5NSS to D5IMBHgb

117Plt 368

Hct 34

Seg 81

Wbc 17.4

Lym 10

Ph 7.53

Pco237

Po2 203

So2 100

Hco3 30.9

Beb 7.8

Na 152

K 3.7

Cl 99 Ca 2.38

9/25/13

Awake, follows commands, (+) alar flaring(+) IC retractionsfair air entry(+) bilat crackles(+) wheezing

(+) febrile episodes(-) phlebitis

Labored breathing(+) alar flaring

CXR Urine KOH neg

D5NSS to D5IMBInc Fio2 to 100%

d/c Clinda and CeftazShift to Pip Tazo (240) Amik (15)

Fio2: 100%Inc PIP to 24PEEP 6RR 30

Ph 7.47

Pco232

Po2 207

So2 100

Hco3 23.3

Beb 0.2

9/26/13

(+) erythematous diaper area

post set up

Zinc oxide creamD5IMB (mtn)d/c KCl incorporationt/s KCl syrup

Dec Fio2 to 90% PIP 24

Ph 7.51

Pco256

Po2 239

So2 100

Hco3 44.7

Beb 18.8

Na 131

K 3.1

Cl 83 Ca 2.1

Ph 7.49

Pco249

Po2 101

So2 98

Hco3 37.3

Beb 12.2

9/27/13

(+) alar flaring(-) reatractions(+) wheezes

Inc PIP to 25

Salb neb stat dose

D5 0.45NaCl (mtn)Deficit: 65TNar: 105CT: 27hrs

Ph 7.39

Pco260

Po2 135

So2 99

Hco3 36.3

Beb 9.3

Na 127

K 3.8

Cl 83 Ca 2.07

9/28/13

(+) febrile episodes(+) desaturations 80%(+) alar flaring(-) retractions(+) crackles bilat(+) wheezes

PipTazi D4+1Amik D3

D5LR (mild + mtn)Ph 7.39

Pco247

Po2 173

So2 100

Hco3 28.5

Beb 2.8

Na 133

K 3.3

Cl 91 Ca 2.1

Hgb 113

Plt 248

Hct 35

Seg 79

Wbc 20.6

Lym 9

9/29/13

Asleep, arousabke(+) febrile episodes(-) alar flaring(-) retractions(+) crackles bilat(-) wheezes

(+) beginning decubitus ulcer

at Fio2 90%

at PIP 26

BMA: normocellular marrow, normal maturation of granulocytic and lymphocytic cell lines, normal megakaryocytes

at RR 32

Inc PIP to 26d/c PipTazo and Amikt/s Meropenem (120)

Inc RR to 32Turning schedule

Inc PIP to 28

Ph 7.36

Pco263

Po2 136

So2 99

Hco3 35.6

Beb 8.1

Ph 7.34

Pco259

Po2 165

So2 99

Hco3 31.8

Beb 4.5

Ph 7.32

Pco253

Po2 186

So2 94

Hco3 27.3

Beb 6.4

9/30/13

(+) post prandial vomiting (20cc)Moist lips and buccal mucosaFull pulses

Merop D1HRZE D14

post set up

post hypervent

MV Fio2: 100%RR 35PIP 28PEEP 6

Hyperventilate

Pulmo: for ET CO2 monitor

Ph 7.36

Pco263

Po2 136

So2 99

Hco3 35.6

Beb 8.1

Ph 7.34

Pco259

Po2 165

So2 99

Hco3 31.8

Beb 4.5

Ph 7.32

Pco253

Po2 186

So2 94

Hco3 27.3

Beb 6.4

10/1/13

Awake, comfortable(-) alar flaring(-) retractionsGood and equal air entry(+) crackles blf(-) wheezes

Merop D2HRZE D15

(+) occ episodes of wheezes

BCS neg

Increase caloric requirements

MV: Fio2 100% RR 35 PIP 28 PEEP 6 PSV 9

Stat salb neb

Ph 7.21

Pco288

Po2 135

So2 99

Hco3 35.2

Beb 4.6

Na 135

K 5

Cl 84 Ca 2.3

10/2/13

Restlessness

3:00AM(+) alar flaring, 99%satsSCE, (+) IC/SC retractions, tight air entry

(+) alar flaring, 99% satsSCE, dec IC/SC retractions, Fair air entry, (+) cracles, (-) wheezes

(+) alar flaringSCE, dec IC retractions, Good and equal air entry, (+) crackles BLF, (-) wheezes

Midazolam (0.2)

Continuous salb neb

10/2/13

5:00AMPULMO:(+) air hunger(+) alar flaring(+) poor air entry despite suctioning post neb(+) diaphoresis

HR 110s

Post intubation: (+) circumoral cyanosis, (+) equal air entry, HR 0, BP 0

s/p 26mins CPRs/p 10 epinephrine doses

ET tip swab AFBET top culture

Re-intubation

Epi q3mins

Pronounced dead: 7:10AM