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CASE ABSTRACT

September 18, 2016


At 1:50 AM, patient arrived unconscious in the ER. Vital signs were the
following: BP 180/140, PR: 62, RR was mechanical ventilator assisted and
with a temperature of 36C. Patient was admitted to ICU under the care of
Dr. Pena. Secured consent for admission and management. On NPO diet.
At 2:35 AM, patient was hooked with PNSS 1 L x 12. The doctor ordered CBC,
U/A, Crea, Na, K, 12 Lead ECG, Chest X-ray, Cranial CT Scan (the following
were done outside the hospital premises), BUN, Lipid Profile, CBG, AST, ALT,
PT and PTT. Ordered medications: Citicoline, Mannitol, Omeprazole and
Atorvastatin. Ordered vital signs and GCS every hour. Ordered a 10 mg.
Nicardipine drip in 90 cc. D5W to maintain SBP < 150 mmHg. Ordered
suction secretion as needed. Done NGT and notified the AP on the admission
and patients status. Set mechanical ventilator at: TV 300, FiO2 100%, AC
mode, RR 18. To update AP once in a while regarding patients status
At 4:10 AM, patients drip revised to 90 cc. PNSS + 10 mg. Nicardipine x 5
ugtts/min to maintain SBP < 150 mmHg, also to follow PNSS 1 L x 12.
At 8 AM, patients BP dropped from 200/100 to 160/100 @ Nicardipine 11
mg/hr (110 cc/hr). Referred to cardiologist.
At 8:10 AM, two cardiologists were referred but both not available
At 8:15 AM, patients BP 160/100 @ Nicardipine 11 mg/hr (110 cc/hr) with
GCS 6 (E1V1M4). Given Coaprovel and Amlodipine for hypertension.
At 8:20 AM, AP was informed of orders from cardiologist Dr. delos Reyes to
maintain BP @ 150-160/90-100 mmHg
At 10:45 AM, patients relatives were updated on status and decided to do all
medical and surgical management to the patient. Referred to neurosurgeon
for consult and ordered increase of Mannitol to 100 cc q 2
At 10:50 AM, neurosurgeon cant be reached through landline and cellphone
and referred next on deck via SMS
At 11:20 AM, neurosurgeon Dr. Colasito was informed and aware of referral
for neurosurgeon consult via phone call.
At 11:40 AM, patients temperature rose to 38. 4C. Given Paracetamol via IV
q 4
At 11:50 AM, CVD hemorrhage, pontine observed via CT scan done last
September 17, 2016. Another CT scan was ordered by Dr. Colasito
At 12:10 PM, patients relatives were advised and explained patients current
condition. Ordered PNSS 1 L x 12.
At 2:00 PM, patient seen with (+) pontine bleed, with GCS 6 (E1V1M4) and
lateral wall ischemia. Relatives were aggressive in management. History
reviewed and entries noted. Under Nicardipine drip. Given Coaprovel drip
with BD after 30 minutes. With BP 160/100 mmHg and HR 104 bpm. Ordered
to continue Coaprovel and Amlodipine as ordered. Plan 2-D Echo and Color
Doppler. Impression seen: s/p CVA, hypertension Stage 2 t/c hypertensive
nephrosclerosis t/c diabetes nephropathy
At 2:15 PM, patient has creatinine (310), with GCS 5 (E1V1M3), pupils 2
mm. RTL. Relatives were updated on condition. Ordered Cranial CT Scan for
confirm brain stem hemorrhage. Neurology ordered labs: Na, K, BUN, Crea.

Referred to pulmonologist for co-management. Also ordered ABG, NPO


except for medication (Ketosteril 600 mg. TID). Inserted separate heplock for
Cerebrolysin infusion, lactulose and CBG monitoring q 8
At 2:50 PM, ABG results were relayed and informed referral for pulmonologist.
Increased TV to 500, decreased FiO2 by 10 q 30 minutes until 40% is reached
to maintain O2 sat at 98% and above. Scheduled for ETA GS/CS. Started on
nebulization (Pulmodual) q 6
At 11:45 PM, patient has GCS 6 (E1V1M4). Advised to watch out for further
deterioration. Ordered to repeat Cranial CT scan tomorrow PM. Anticipated for
the possibility of external ventricular draining (EVD) and explained to patient
and follow up.

September 19, 2016


At 10 AM, patient had GCS 5 (E1V1M3) with O2 sat of 97% at 40% FiO2.
Ordered to repeat ABG.
At 12 PM, vital signs were noted and given PNSS 1 L x 12 for 2 cycles
At 12:55 PM, patients O2 sat was at 98% @ 48% FiO2. Ordered to decrease
FiO2 at 35%
At 3:45 PM, patients pupil were at 2mm RTL with GCS 6 (E1V1M4) with no
spontaneous breathing. Condition unchanged from yesterday and updated
relative.
At 3:50 PM, CT scan were relayed. No significant progression and no
hydrocephalus. Carried on with the present management.
At 4 PM, ETA GS indicated: epithelial cells few, pus cells - >50 hpf, gram(+)
cocci 3+, gram(-) bacilli few and (+) yellowish secretion per ET. Ordered
Piperacillin+Tazobactam (Vigocid) IV qid
At 5:40 PM, patient started with Terazosin 5 mg. tab q 8 PM daily.
At 5:50 PM upon admission to ER, patient arrived unconscious. Vital sign was
BP 100/90. Patients medication were given as ordered: 10 mgs. Amlodipine,
300/25 mg. Coaprovel and 10-20 gtts/min Nicardipine drip. Gave 2 mg.
Terasozin NGT OD every 8 PM duty. Started 5 mg. Ivabradine (Coralan) NGT
OD
At 6:57 PM, CBG results relayed at 121 mg/dL. Started OF of 1,500 kcal/day
divided into 6 equal feedings. Discontinued CBG monitoring upon starting on
OF.
September 20, 2016
At 2:45 PM, patients O2 sat around 96-97% @ 35% FiO2. Given Fluimucil 60
mg. to dissolve in 50 cc water bid. Reduced dosage Vigocid to 2.25 mg. IV q
8
At 3:48 PM, patients GCS 5 (E1V1M3), pupils at 3 mm. RTL, I/O 4667/2260
and with (+) spontaneous shallow breathing. Ordered for repeat CBC, Na, K,
BUN and Crea. Shifted Omeprazole IV to Omeprazole 40 mg/cap OD. Referred
to nephrology for evaluation and management. Also to repeat Cranial CT scan
tomorrow morning.
At 4:10 PM, contacted 3 nephrologists but all were not available and updated
Dr. Pena. Increased Ketosteril to 2 tabs tid.

At 5:05 PM, Nephrologist Dr. Guce answered back and aware of the referral.
Suggested to decreased TV to 100
At 5:25 PM, Dr. Alcantara updated the orders via phone.
At 9 PM, Dr. Alcantara ordered to increase TV to 400 and to repeat ABG after
2 hours.
At 9:20 PM, potassium was observed and started the patient with K-Lyte 2
tabs tid
At 9:30 PM, Dr. Guce from nephrology viewed and examined patient. Findings
showed that patient had chronic kidney failure and done the following
instructions: advised to continue ketosteril, transfusion of 2 u PRBC properly
typed and crossmatched once available, hemodialysis with attached consent,
IJ insertion with consent, gave NaHCO3 with 250 D5W x 12 x2 cycles,
increased TV to 500 as recommended by Dr. Alcantara

September 21, 2016


At 1:55 AM, advised to vigocid 2.25 g. q 12. Scheduled for HBsAg, antiHBS,anti-HCV with consent. Prescribed dialysis were as followed: duration 4
hours, UFR: 0.5 L, no heparin, dialyzer F7 or equivalent, QB: 250, QD: 500,
with bicarbonate bat, dialysate temp: 36, dialysate sodium: 140, dialysate
potassium: 2.0 and with PNSS 1 L x 12
At 7 AM, patient consented on the IJ catheter insertion and hemodialysis.
Referred to TCVS for IJ catheter creation.
At 8 AM, patients relatives were been aware on the referral to TCVS and
anesthesiologist
At 8:20 AM, patients relative was aware of referral, noted history and
reassessed patients GCS 6 (E1V1M4) and intubated. Scheduled for IJ
insertion at 11 AM. Referred to anesthesiologist and OR. Secured consent with
no pre-op meds.
At 8:30 AM, four anesthesiologists were contacted and Dr. Dizon was the only
available one on deck who was aware of the patients status. Asked Dr.
Desquitado to reschedule patient at 10 AM
At 9 AM, Dr. Alcantara and Dr. Pena were aware of the above orders via phone
call. Updated other APs through SMS. Cranial CT scan was done and results
were sent via Viber
At 9:45 AM, informed on the order and rescheduled OR at 10 AM by Dr.
Desquitado
At 10 AM, patient was sent back to ICU and connect ventilator with the same
settings. Monitor v/s q 15 minutes until stable. Scheduled for x-ray, continued
OF, regulated IVT at 60 cc/hr and continued all previous medications.
At 11 AM, s/p IJ insertion, patient had AKI, oliguric phase, hooked on IVF TF
PNSS 1 L x KVO to IVF PNSS x KVO, increased UFR at 2.5 L, consumed
bicarbonate drip, rescheduled for hemodialysis for tomorrow, duration = 4
hours, UFR: 2 L, heparin free, with bicarb bath, QB: 250, QD: 500. Dr. Marcial
was OOC and covered by Dra. Marcial.

At 1 PM, ICU inquired regarding on pre-BT drugs. Informed re: blood


(leukoreduce). Dr. Guce gave Paracetamol for pre-BT and also approved for
leukoreduce blood on BT.
At 1:30 PM, patient was for HD. Doctor approved to increase FiO2 to 100%
while on HD
At 2:10 PM, patients v/s: BP 80/40 mmHg, O2 sat 99%, Spent 30 min on HD.
At 4:30 PM, cardio meds were given: Amlodipine, Coaprovel, Terazosin,
Coralan and Atorvastatin.
At 4:40 PM, Dr. Pena reduced Mannitol to 50 ml. q 6
At 10:30 PM, Dr. Pena prescribed 2 u PRBC to run for 4-6 hours. For
reassessment after transfusion c/o ROD.

September 22, 2016


At 8:30 AM, patients GCS 5 (E1V1M3), SCE CBS, transfused 2 nd unit PRBC.
At 10:00 AM, patients GCS dropped to 3-4 (E1V1M1-2), pupils 2 mm RTL, BP
range 100-120/70-80. Put all anti-hypertensive drugs on hold. Relatives were
updated on the poor prognosis of the patient. Best case scenario was
persisted in vegetative state.
At 1 PM, talked to Dr. Marcial through phone call regarding referrals.
At 2:30 PM, Dr. Pena and Dr. Guce were informed on Dr. Marcials decision
regarding referral through phone call and SMS respectively.
At 3:20 PM, patient was seen and examined by Dr. Alcantara with NND.
At 8:20 PM, done with HD and BT 2 u PRBC. Vital signs: BP 140/90, PR 70-80,
RR 18, O2 Sat 98%, (-) spontaneous breathing, (-) corneal reflex. Ordered for
repeat CBC, Na, K, BUN, Crea 12 hours post BT.