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ID and Biodata
Age: 52
Sex: Female
Occupation: Receiptionist
Address: Bandar Baru, Permyjaya, Miri
Date of Admission: 27/12/2015
Date of Death: 19/1/2016
Cause of Death: ischaemic heart disease with
decompensated CCF
Clinical Presentation
Referred by ENT team in ED TRO respiratory
illness
52 years old lady, underlying hypertension, OSA
and post total thyroidectomy for MNG complicated
with hypocalcemia.
Presented with SOB and fever for 1 day.
SOB progressively worsening at 5 am on the day
of admission
No cough, nausea, vomitting or abd pain
Had history of orthopnea and PND
Snore during sleep
3
Examination on admission
Investigations on admission
ABG (on
neb)
ABG (on
BiPAP)
pH
7.15
pH
7.12
pCO2
104.4
pCO2
131.5
pO2
55.7
pO2
59.9
HCO3 28.5
BE
5.3
SO2
79.4
%
RP
FBC
WCC
15.6
urea
10.9
Hb
13.9
creat
123
Plt
354
Na
136
Hct
48.9
4.0
Cl
91
CX
R
Cardiomegaly,
Bilateral lower zone haziness
EC
G
Initial management
Suggest for intubation in view of
impending respiratory collapse due to
worsening CO2 retention/ respiratory
acidosis-intubated by anaest team
IV augmentin 1.2g TDS
IV frusemide 40mg TDS
Sent blood C+S, sputum AFB, sputum
C+S, urine C+S, urine FEME
Progress in ward
Date
Progress
medication
27/12/1
5
(day 1
intubat
ion)
supported
with
iv
*IV Rocephine 2g OD
*IV Ca Gluconate 1g stat
*s/c clexane 60mg OD
*IV tranexamic acid 500mg
TDS
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
29/12/15
Day 1 ICU
admission
TRO
leptospiro
sis
AKI
NSTEMI in
failure
*IV cefepime 1g BD
Withold s/c clexane
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV tranexamic acid 500mg
TDS
Iv omeprazole 40mg BD
Spiking fever,
Bp supported by iv noradrenlaine, adrenaline and dobutamine
Poor urine output (20-30cc/h)
Feeding withold
Off sedation
Reviewed by ENT: bilateral nasal packing removed
Flexible scope: no active bleeding at nasopharnyx or other area of
nasal cavity. Slight raw area at nasopharynx and nasal cavity
IV cefepime 1g BD (D2)
Iv frusemide 5 mgSTAT
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV tranexamic acid 500mg TDS
Iv omeprazole 40mg BD
IVD 60cc/h
Blood c+s: NG
Date
Progress
Medication
31/12/1
5
IV cefepime 1g BD (D3)
IV lasix 5mg STAT
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV tranexamic acid 500mg TDS
Iv omeprazole 40mg BD
2/1/16
Date
Progress
Remark
3/1/16
IV cefepime 1g BD D6
Ivi lasix
Oral kalimate 10g TDS
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV tranexamic acid 500mg TDS
T omeprazole 40mg BD
4/1/16
Iv mida morphine
Iv noradrenaline
Iv cefepime D7
Neb AVN 6 hrly
Oral kalimate 10g TDS
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
Date
Progress
Remark
5/1/16
Ivi lasix
Iv noradrenaline
*Iv EES 250mg BD
Ravin enema II/II OD
Syrup lactulose 15 mls TDS
IVD 1 pint/day all NS
7/1/16
8/1/16
Iv cefazoline 2g EOD
x2/52(during HD)
Ivi lasix
Iv glymine
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV cefazolin
IV EES
*Ivi lasix off
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
IV cefazolin
IV EES
Oral kalimate 10g TDS
Iv omeprazole 40mg OD
Iv EES 250mg BD
Iv lasix 40mg TDS
Date
Progress
Medication
9/1/16
IV cefazolin
Oral kalimate 10g TDS
Iv omeprazole 40mg OD
Iv EES 250mg BD
Iv lasix 40mg TDS
10/1/1
6
*Off EES
11/1/1
6
Iv cefazolin
T calcium lactate 1.2g TDS
T rocaltriol 0.25mg BD
T CaCO3 2g TDS
T L-thyroxine 100 mcg OD
T tranexamic acid 500mg OD
Iv lasix 40mg TDS
Put on TM 50%
HD done,completed 4 hour under tight heparin. Extract
2L
Urea: 66.4-> 50.7
Creatinine: 815-> 683
K: 6.1-> 4.0
VBG: ph 7.27,PCO2 43, PO2 43, HCO3 19, BE -6.9, SO2
71%
13/1/1
6
Date
Progress
Medication
15/1/16
IV cefazolin
*T haematinics
T CaCO3 1g TDS
T frusemide 40mg OD
T omeprazole 40mg OD
Syr lactulose 15ml ON
T calcitriol 0.25mcg OD
16/1/16
IV cefazolin
T haematinics
T CaCO3 1g TDS
T frusemide 40mg OD
T omeprazole 40mg OD
Syr lactulose 15ml ON
T calcitriol 0.25mcg OD
ABG= pH 7.49, pCO2 39, po2 88, HCo3 29.5, BE -5.9, So2
97%
1718/1/16
19/1/16
IV cefazolin
T spironolactone 25mg OD
T haematinics
T CaCO3 1g TDS
T frusemide 40mg OD
T omeprazole 40mg OD
Syr lactulose 15ml ON
Date
Specimen
Antibiotic
27/12/15
Blood c+s: NG
IV augmentin
(2728/12/2015)
28/12/2015
Blood c+s:
staph
coagulase ve,
MRO +ve
S-linezolid,
vancomycin
Iv rocephine 1g
BD
29/12/15
Urine c+s: NG
ETT c+s: NG
Iv cefepime 1g
BD (29/12/154/1/16)
30/12/15
Blood c+s:NG
ETT c+s: NG
Urine c+s: NG
Iv cefepime 1g
BD (29/12/154/1/16)
4/1/16
Blood c+s: NG
Iv cefepime 1g
BD (29/12/154/1/16)
THANK YOU
18