icp blue team

8/19/2019 Icp Blue Team

1/13

CASE REPORT54 year old male

Minalin, Pampanga

Admitted Dec. 26, 2015

Cc: Tumor on the left thigh


2/13

4 monthsPTA

•Single, nontender, enlarged left inguinal lymph node•IM Clinic in Pampanga•Unrecalled liver problem•Unrecalled medications decreased size of inguinal LN

3 monthsPTA

•Multiple erythematous papules over the anterior aspect of patient’s leftthigh

•No pruritus or tenderness•Surgeon in Pampanga Herpes Zoster•Unrecalled antivirals for 10 days and vitamins

2 monthsPTA

• Advised consult with a dermatologist•Referred to USTH for further evaluation and management


3/13

1 1/2months PTA

•USTH Surgery OPD•Biopsy – Benign Tumor•Unrecalled pain medications

•Swelling of patient’s left leg

•USTH Dermatology OPD- Dermatofibrosarcoma

1 monthPTA

•USTH IM OPD•Tramadol and Clindamycin

•

Malunggay leaves extract•Progression in size and number of the tumor• Anorexia, weight loss

5 days PTA

•BCI• Advised admission


4/13

Admission

• VS stable•Multiple, erythematous, firm, nontender, nodules over left thigh, leftinguinal area, and genital area; (+) pitting edema on left lowerextremity; edema of both testicles; and MMT 4/5 LLE

•Sepsis secondary to infected tumor, Left thigh; Dermafibrosarcoma,Left thigh

•Low haemoglobin (99) and haematocrit (0.31), high platelet count (550),and normal WBC (7.90) with predominance of neutrophils (0.78)

•Normal Crea, Na, K•U/A - positive leukocytes and erythrocytes, minimal pyuria, andamorphous urate

•CXR- bibasal pneumonitis, minimal pleural effusion &/or thickening• X-ray of hip - soft tissue densities at the proximal ½ of the left thigh•

Vancomycin 1g/IV in 90cc PNSS to run for 1-2 hours, first dose given atthe ER then every 12 hours thereafter•Piperacillin-Tazobactam 4.5gm in 90cc PNSS to run as IV infusion for1-2hrs, first dose given at the ER then every 6 hours thereafter

•Tetanus toxoid 0.5mL/IM; tetanus immune globulin 250 IU/IM•Celecoxib 200mg/cap 1 cap every 8 hours as needed for pain•Paracetamol 500mg/tab 1 tab every 4 hours for temperature >38.3


5/13

Admission

• Dermatology• Malignantlymphoproliferative disorders/p skin punch biopsy

• Orthosurgery•

Conservative management• Wet to dry dressing


6/13

2nd HD

• Tramadol + Paracetamol (Algesia) 1 tab every 6 hours• Peptamen 6 scoops in 1 glass of water TID•

Piperacillin-Tazobactam was decreased to 4.5gm/infusionevery 8 hours

3rd HD

•Decreased pain on the left lower extremity•

Vancomycin increased to 1250 mg/IV in 90 cc PNSS• Vancomycin trough level was within normal range (8.30)

5th HD

•

Wound tissue CS revealed E.Coli (ESBL positive) few,with moderate growth of Proteus Mirabilis• Occasional pain on his left leg with yellowish foul smellingdischarge from the tumor


7/13

6th HD

•Tenderness on palpationand warmth over the leftflank and LUQ area

8th HD

•Whole Abdomen UTZ with Doppler•Borderline sized to slightly enlarged liver with diffuse parenchymalchanges secondary to fatty infiltration

•Multiple hepatic complex masses, both lobes; consider multiplehepatic abscesses with vascularity

•Splenic cyst; normal gallbladder, pancreas, both kidneys and urinarybladder

•Grade II prostatic enlargement with concretions•Incidentally, left sided pleural effusion

• Anemia and leukocytosis with predominance of neutrophils


8/13

9th

hospital day

• Referred to surgery for debridement

10th

hospital day

• febrile (Tmax=39 C• Paracetamol 500mg/tablet- temporary relief• scrotal sling and Clotrimazole cream on inguinal area.

17th

hospital day

• (+)facial asymmetry and sudden perioral numbness, difficultyprotruding the tongue.

• Neuro Dx: intracranial (Brainstem) metastasis.• left mandibular mass.


9/13

18thhospital day

• BP elevations of SBP 130-150 Amlodipine 5mg/tab OD.• Advised Panorex Scan of the Mandible and flexiblenasopharyngolaryngoscopy

20th

hospital day

• shortness of breath (RR of 40)(+) crackles both lung fields• CXR : bilateral alveolar infiltrates; pleural effusion, R• HAP, with possible aspiration component, Pleural effusion, B,R>L, probably due to a parapneumotic process vs

hypoalbuminemia• ultrasound of both hemithorax; Meropenem Imipenem 500mgSputum GS/CS ; advised 2D echo with Doppler AmlodipineEnalapril 5mg/tab 1 tab OD ;Azithromycin 500mg/tab 1 tabOD.


10/13

21st

hospital day

• normotensive tachycardic (HR

110) tachypneic (RR 24)decreased breath sounds, T7down, L and (+) crackles on the Rlung base.

•

Furosemide 40mg/IV, decreasedIVF rate to 20cc/hr.• Imipenem (D1) Vancomycin (D7)and Azithromycin (D1)

• NaHCO3 2 tabs TID. CBC withplt, SGPT, SGOT, Na/K-requested

• Plan: Thoracentesis;CTT/JPdrain insertion


11/13

22nd

hospital day

• ultrasound of the hemithorax: bilateral

pleural effusion with relaxation atelectasis.• Furosemide 40mg/IV• Reappraised for drainage of pleuraleffusion

23rd

hospitalday

•

Algesia 1 tablet every 6 hours RTC;Enalapril 5 mg/tab 1 tab OD


12/13

24th

hospital day

•

underwent ultrasound guidedthoracentesis of the righthemithorax 90 cc ofxanthochromic turbid fluid sentfor pH, glucose, differential

count, cell count, gram stain,culture and sensitivity, AFBstain, MTB culture andsensitivity and cell cytology.

•

serum creatinine-0.54• relatives expressed desire tobring the patient home due tofinancial constraints.


13/13

icp blue team

Documents