1. MORTALITY CASE REPORT

2. Patient Data C.M.E. 9 months old, female From Quezon City Informant: mother (70% reliability)

3. CHIEF COMPLAINT Difficulty of Breathing

4. History of Present Illness 6 days PTA Undocumented fever No associated symptoms No consult, no meds 1 day PTA Still with undocumented fever (+) loose stools, watery, yellowish, nonbloody >10 episodes per day Overflowing the diaper, (+) passage of worms (+) postprandial vomiting, poor suck and activity Day of admission Persistence of symptoms Consult with private MD, given ORS, sent home (+) DOB, gasping CONSULT

5. Birth and Maternal History Born to a 23 years old G2P2 (2002), non-smoker, non- alcoholic beverage drinker (+) PNCU at LHC Denies any maternal illness (+) Multivitamins and ferrous sulfate intake Ultrasound done at 7 months AOG: Normal Delivered full term via NSD at Bicol hospital attended by a midwife No MSAF, no cord coil, no feto-maternal complications Discharged after 24 hours. BW = 2.7 kgs.

6. Nutritional History Breastfed exclusively for 6 months Complementary feeding at 6 months

7. Immunization History BCG – 1 DPT – 3 Hepatitis B – 3 OPV – 3 Measles - 1

8. Growth and Developmental History Currently, patient can… Sit alone, crawl Do pincer grasp Say “Papa” Smile (starting 2 months old)

9. Family History Paternal: (+) Bronchial Asthma Maternal: (+) Epilepsy No family history of hypertension, DM, malignancy, goiter, PTB 26 Garbage Collector 24 Housewife 3

10. Personal and Social History Lives in a rented house with fair ventilation and fair lighting Household members: 8 Garbage is collected 3x a week Drinking water: mineral No exposure to cigarette smoke Neraby piggery

11. Past Medical History At 8 mos: (+) afebrile seizure – no consult, no meds No prior hospitalizations No previous surgeries

12. Physical Examination Drowsy, in cardiorespiratory distress Wt: 7 kg Ht: 75 cm BP 0 HR 170 RR 40s, gasping T 40C Pale conjunctivae, anicteric sclerae, sunken eyeballs Dry lips, moist oral mucosa Symmetric chest expansion, no retractions, clear breath sounds Adynamic precordium, tachycardic, regular rhythm, no murmur Flat abdomen, normoactive bowel sounds, no palpable masses Poor skin turgor Weak pulses, cold extremities, CRT > 3 secs

13. Physical Examination CN I – not assessed CN II – 2-3mm pupils, ERTL CN III, IV, VI – full EOMs CN V – good masseter tone CN VII – no facial asymmetry CN VIII – turns to sound CN IX, X – intact gag reflex CN XI – turns head from side to side CN XII – no tongue deviation Spontaneously and equally moves all extremities Withdraws to pain No nystagmus DTRs +2 No Babinski, no clonus No nuchal rigidity

14. WORKING IMPRESSION Hypovolemic Shock secondary to GI losses AGE with severe dehydration Intestinal parasitism

15. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/19 8:20 PM BP 0 HR 170 T 40 Gasping Weak pulses, cold extremities CRT > 3 secs CBC: Hgb 106 Hct 31 WBC 38.3 Seg 44 Lympho 52 Plt 457 Na 136 K 4.2 Cl 108 Ca 2.01 ABG: pH 6.91 pCO2 15 pO2 200 O2sat 99 HCO3 3 BeB -28.3 BUN 8.3 Crea 112 RBS 5.5 AST 44 ALT 13 TPAG: 59/30/38/1.1 Hypovolemic shock sec to GI losses AGE with severe dehydration PNSS (10) / NGT PNSS (20) / IO

16. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/19 9:30 BP 120/70 HR 190 Cold extremities Fair pulses Grunting and gasping Sunken eyeballs (+) seizure: UREB, nonreactive pupils for 5 minutes Post-ictal: (+) clonus, bilateral Hypovolemic shock sec to GI losses AGE with severe dehydration Hypoxic Encephalopathy RSI Intubate: size 4, level 12 Refer to ICU Diazepam (0.3)

17. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/19 10:00 PM Intubated on CAB CXR: selective intubation, R>L, (+) infiltrates PneumoniaAdjust ET to level 10.5 Ampicillin (100) 10/19 10:45 PM Intubated on CAB, awake with spontaneous movement PT: 14.3/11.2/62.7/1. 28 PTT: 35.1/29.8 ABG (1 o post- intub): pH 7.55 pCO2 12 pO2 329, O2sat 100, HCO3 10.5 Beb - 8.7 Hgt 44  93 Hypoxic Encephalopathy Hypoglycemia Vitamin K (1) NaHCO3 (0.6) D10W (5)

18. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 1:20 AM BP 100/60 HR 140 RR on CAB T 39C O2sat 98 Awake, pupils 2- 3mm ERTL SCE, clear breath sounds, good air entry Full pulses, warm extremities, CRT < 2 secs Hypovolemic shock sec to GI losses AGE with severe dehydration Paracetamol suppository D5IMB (MTN) 10/20 2:00 AM BP 100/60 Awake, comfortable (+) Spont breathing Nonsunken eyeballs, moist lips Full pulses, CRT <2 secs For Blood CS, stool CS, stool exam t/c SepsisTransfer to wards

19. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 4:20 AM (+) watery, mucoid stools Replace losses with PLR vol/vol 10/20 7:30 AM (+) spontaneous breathing, no retractions, no cyanosis ABG: pH 7.48 pCO2 10 pO2 267 O2sat 100 HCO3 7.4 Beb -12.7 PT: 22.2/11.1/32.1 /2 Compensated metabolic acidosis, overcorrected hypoxemia Sepsis For repeat PT and PTT on day 3 of Vit K 10/20 8:00 AM T 40CParacetamol (10)

20. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 9:10 AM BP 160/100 HR 160 RR on CAB T 40 (+) nystagmus Decrease in sensorium: no active movement, does not withdraw to pain Pupils 2-3mm ERTL Enlarged, tympanitic abdomen Yellowish, mucoid stool Brownish output per OGT Hgt: Low ABG: pH 7.36 pCO2 17 pO2 264 O2sat 100 HCO3 9.6 BeB -13.4 Metabolic Encephalopathy t/c CNS Infection D10W (5) NPO for now

21. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 10:20 AM BP 0 HR 180-200 T 40 O2sat 84% Clear breath sounds Weak pulses CRT 4 secs, cold extremities I: 900 O: 120 FB +780 CBC: Hgb 71 Hct 22 WBC 16.5 Seg 52 Pympho 38 Plt 156 Na 146 K 3.4 Cl 117 Ca 1.99 Septic ShockPNSS (20) Refer to PIDS for use of Ceftri Genta (5) Dopa (10) BP 60 30 HR 180 Weak pulses, CRT 3 secs Septic ShockPNSS (20)

22. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 10:55 AMBP 110/70 HR 190 Cold distal extremities Fair proximal pulse CRT 3 secs Septic ShockIVF (TFR = 10) 10/20 11:00 AM (+) feverABG: pH 7.3 pCO2 19 pO2 191 O2sat 100 HCO3 9.3 BeB -14.9 Septic ShockShift Ampi to Ceftri (100) 10/20 11:05 AM Brownish to bloody output per OGT Disseminated Intravascular Coagulopathy Omeprazole (1)

23. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 11:35 AM BP 0 HR 195 O2sat 93% CRT 3-4 secs (+) tea-colored urine Septic shockPNSS (20) Epinephrine drip (0.2) NaHCO3 (0.3) BP 80/50 HR 175 O2sat 98% Cold toes, compressible pulses

24. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 12:00 NN BP 0 HR 200 Cold extremities CRT 4 secs Septic ShockEpi (0.3) 10/20 12:35 PMBP 90/60 HR 200 T39.6 Clear breath sounds Good pulses CRT 2-3 secs Cold toes Na 141 K 3.10 Cl 112 Ca 1.4 Crea 114 GFR 24 Bili 0.5/0.1/0.4 PT 32.3/11.2/19.8 /2.92 PTT 47.9/29.4 Septic Shock DIC Aggressive TSB IVF at TFR 10 for 1 hour Refer to RT for mechanical ventilator 10/20 1:30 PM BP 90/60 HR 200 Good pulses UA: yellow/sl hazy/1.009/7/ gluc trace/prot +1/RBC 1/WBC 5 Decrease IVF rate to 2x MTN

25. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 3:00 PM Septic-looking Highly febrile No crackles Warm extremities, full pulses TPAG: 41/20/21/1 ALT 177 AST 595 BUN 11.8 RBS 5.10 SepsisDecrease IVF rate to 1.5x MTN K correction (KIR: 0.25) For PRBC transfusion Cal gluc 10mL 10/20 3:30 PM RestlessMidazolam drip (2) 10/20 4:15 PM On CABABG: pH 7.35 pCO2 27 pO2 73 O2 sat 94 HCO3 14.9 Beb -19.2 Compensated metabolic acidosis, undercorrected hypoxemia NaHCO3 (0.3)

26. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 4:30 PM HR 170s T 40.5 C Awake, highly febrile Pupils 3-4mm ERTL No jaundice (+) SC retractions, clear breath sounds Distended abdomen Liver edge 3-4cm BSCM CRT 2-3 secs (+) hematuria (+) coffee ground mat’l / OGT Discontinue Ceftriaxone T/s Piptazo (240) q6 Continue Genta

27. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 6:15 PM BP 0 T 41.1 Cold distal extremities, weak pulses PNS (20) Epi (0.5) Dopa (15) FFP 150 mL BP 80/50 HR 180 (+) hematuria 10/20 7:20 PM BP 80/50 HR 204 O2 sat 84-86% Fair Pulses Urine KOH: (-) Fecalysis: green, mucoid, WBC 4-6/hpf Septic Shock DIC AKI t/c MODS Admit to ICU D5LR (1.5x MTN) For CUTZ, TACS For FFP, PRBC MV settings: FiO2 100 RR 30 PIP 15 PEEP 5 Refer to Nephro Adjust PipTazo to renal dose

28. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 8:15 PM I: 2251 O: 600 FB +1651 LSE: 9AM 10/20 9:50 PM Desaturations up to 74% on MV BP 80/50 HR 180- 195 T 38.6 C (+) rales, bilateral Full pulses CXR: ET in place, bilateral infiltrates Increase PEEP to 6 10/20 10:00 PM Still with destauration on vent support (O2 sat 78-82%) On CAB: O2 sat 96-98% Increase PIP to 16  17  18 Patients appraised

29. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 10:15 PM BP 80/50 HR 180- 200 Warm extremities, full pulses O2 sat 94-95% on CAB Maintain on CAB 10/20 10:40 PM BP 0 HR 150s O2 sat 80% Good air entry, (+) crackles, bilateral Warm ext, no pulses PNSS (20) Increase Dopa to (20) Increase Epi to (1) BP 0 HR 180s Warm ext, no pulses Pupils 4mm NRTL Voluven (20)

30. Course in the Wards DateS/OLabsAssessmentPlan/Intervention 10/20 10:40 PM BP 0 HR 0CPR for 15 mins Epi q3 mins BP 0 HR 180s no pulses Pupils 5mm NRTL Voluven (20) 10/20 11:05 PM BP 0 HR 0MODSPronounced dead

31. MORTALITY DIAGNOSIS Multiple Organ Dysfunction Syndrome (CNS, renal, pulmonary, hepatic, DIC) Sepsis AGE with severe signs dehydration Intestinal Parasitism

32. Update Blood CS result: No growth after 5 days