Professional Documents
Culture Documents
REPORTS AND
PRESENTATIONS
CASE MANAGEMENT
CONFERENCES
General Objective
Clinical Management
Conference To be able to accurately diagnose and
properly manage a patient with acute
De Leon, Adrian post-streptococcal glomerulonephritis.
Fortuno, Karen
Gallarzan, Czarinna
Malimban, Oliver
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6/9/2018
• 2 days PTA
•(+) non- productive cough - • 1 day PTA
•(+) colds - thick, whitish discharge •(+) non- productive cough -
•(+) facial swelling and periorbital edema •(+) colds - thick, whitish discharge
•(+) vomiting - previously ingested food, billous, non-greenish, •(+) facial swelling and periorbital edema
non-bloody •(+) vomiting - post-prandial
•(+) epigastric pain - intermittent •(+) abdominal pain- RLQ, intermittent, relieved by hot
•Consult with a General Practitioner compression
•prescribed with Cefuroxime (38 mkD) and Cetirizine (1mg/mL 5 •no medications taken
mL OD)- did not relieve vomiting, abdominal pain and cough
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6/9/2018
Immunization History
Developmental History
• allegedly complete from the health center
The patient is at par with age. The mother has no developmental
concerns regarding the development of her daughter.
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6/9/2018
• siblings had previous cough and colds • pets at home (pig, dog, chicken)
• exposed to gadgets at 1 year of age; screen • garbage not segregated, not collected, thrown
into the river
time: up to 2 hours per day
• other activities: playing with other children • tap water for drinking
Physical Examination
General Survey
• General Survey
• Vital Signs
• Patient is well developed, well nourished, conscious,
• Anthropometrics and coherent, appears her chronological age of 6-
• Growth Chart Classification years and is not in cardio-respiratory distress.
Other measurements:
Abdominal circumference: 56.5 cm
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6/9/2018
Weight-for-age: +1 (Normal)
Height-for-age: 0 (Normal)
BMI-for-age: 0 (Normal)
Weight-for-age: +1 (Normal)
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Inspection
Head and Neck (+) symmetrical Eyes
(+)reactive pupils (3-4mm)
(+)periorbital edema
Inspection (-) sunken eyeballs
(+) black hair color (+) pink conjunctiva
(+) fair amount of hair with normal distribution (-) cornea or lens opacities
(+) normocephalic (-) nasolacrimal duct swelling, mass, discharge
(+) facial swelling
EOM Movements:
Duction
Palpation Version
(+) submandibular and anterior cervical
lymphadenopathy with tenderness
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6/9/2018
Abdomen Abdomen
Palpation
Inspection (+)soft abdomen
Globular, non-distended, symmetrical with inverted (+) direct tenderness on the L lower
umbilicus quadrant (-) guarding
(-) scar, discoloration, lesions, visible mass, visible
peristalsis nor visible pulsations Percussion
(+) tympanitic all over four quadrants
Auscultation
Low pitched, normoactive bowel sounds at 15 Special Maneuvers
(+) bilateral CVA tenderness
bowel sounds per minute
Liver span: 7cm
Musculoskeletal
Neurologic Examinations
(-) swelling
• Mental Status Examination
(-) deformity
(-) mass • Cranial Nerves
(-) edema • Motor System
(-) limitation of motion • Reflexes
(-) tenderness • Sensory
Full and equal pulses • Cerebellar Exam
• Higher Cortical Function Testing
• Meningeal Testing
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Reflexes Sensory
INITIAL IMPRESSION
Cerebellar POST STREPTOCOCCAL ACUTE
Exam GLOMERULONEPHRITIS
Bases
(-) Nystagmus
History Physical Examination
Finger to nose test (-) dysmetria
6 year old Hypertension - BP=130/100 mmHg
Epigastric tenderness Tachypnea - RR=36cpm
Sore throat and dysphagia Abdominal circumference: 56.5cm
Higher Cortical Function Testing Fever (+) Erythematous Papular Rash at the
Facial swelling lower extremities
(-) Aphasia Periorbital edema (+) Facial swelling
(-) Apraxia Vomiting (+) Periorbital edema
(+) Hypertrophic tonsils (Grade II)
(-) Agnosia (+) Submandibular and anterior
cervical lymphadenopathy
Meningeal (+) Globular abdomen
(+) Direct tenderness on the Left
Testing lower abdomen
(+) Bilateral CVA tenderness
(-) Brudzinski’s sign
(-) Kernig’s sign
Non-Renal
Rule-in Rule-out
Differential Diagnosis
1.Hemolytic Anemia Hematuria (-) organomegaly
(-) hepatomegaly
Renal Non-Renal
2.Hepatitis Edema (-) jaundice
(-) hepatomegaly
Infectious Non Infectious 3. Sub-acute bacterial (+) streptococcal infection (-) murmur
endocarditis (+) edema (-) easy fatigability
(-) dyspnea
Nephrotic Nephritic
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6/9/2018
Nephrotic Nephritic
Non Infectious
Nephrotic Nephritic
Differential Diagnosis
Nephritic Course in the wards
Rule-in Rule-out
Throughout her hospital stay, the patient was placed on fluid limitation
1.IgA Nephropathy or (+) hematuria Can be rule out with
Berger disease (+) hypertension Urinalysis for the first 24 hours and on low salt, low fat, no pork, no beef diet.
(+) edema
(+) abdominal tenderness
Daily weight, blood pressure, urine input and output, and
2.Membranous (+) hypertension Can be rule out with C3
Glomerulopathy (+) edema
abdominal circumference were strictly monitored.
(+) hematuria
CBC, BUN, creatinine, ASO titers, C3 and KUB
3.Henoch-Schonlein (+) hypertension Can be rule out with ultrasound were requested.
Purpura Nephritis (+) edema creatinine and BUN
(+) previous streptococcal
infection Medications given were Nifedipine 5mg tab (0.6 mkD) maintained
(+) erythematous papular
rash at the lower extremities
every 8 hours then every 6 hours as needed if BP>120/90 (0.85
(+) abdominal tenderness mkD) and Furosemide 25mg IV every 12 hours (1.06 mkd)
(+) fever
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Hemoglobin 96 Low
WBC Count
0.29
10.5
Low
Basophils 0.01
Monocytes 0.04
MCV 82.6
MCHC 326
RDW 12.6
KUB result
BUN, Creatinine, C3 and ASO
Both kidneys have homogenous parenchymal echogenicity.
titers
Right kidney measures 8.0x3.6cm
(normal length for age = 6.32 to 8.12cm) with parenchymal thickness of 0.7cm
07/04/2017 Interpretation
While the left kidney measures 8.5cmx4.3cm (normal length for
BUN (Blood Urea 5.2 (3.0 - 9.2) mmol/L Normal age = 6.72 to 8.56cm) with parenchymal thickness of 0.9cm .
Nitrogen) No caliectasia or renal lithiasis seen.
Creatinine 47.5 (53-97) umol/L Low
Urinary bladder is moderately filled with smooth, non thickened walls and no abnormal
ASO titers 400 (<200) IU/ml High
intravesical echoes seen, the total amount of urine in bladder is approximately 500cc,
C3 195 (1032 - 1495) mg/dL Low
which was reduced to 1.6cc on post void scan.
Ph 6.0
Wt: 23Kg, Abdominal Circumference: 53cms, BP: 130/100,
Albumin +1
Intake: 520ml Output: 950ml (Urine Output 1.72 cc/kg/hr)
Sugar Negative
WBC 30-35/HPF Medications were continued and Furosemide IV was shifted to 20mg/tab PO 1 tab every
12 hours (0.87 mkd). Fluid limitation was discontinued
RBC 40-45.HPF
Bacteria +1 Repeat urinalysis was done
Mucus Threads +3
Casts: White Cell (Plus) 1-2/LPF
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Non Infectious
Nephritic
1.IgA Nephropathy or (+) hematuria (-) proteinuria 6 year old Hypertension - BP=130/100 High ASO titer 400
Berger disease (+) hypertension (-) History of viral sydrome Abdominal tenderness mmHg
(+) edema (+) low C3 Sore throat and dysphagia Tachypnea - RR=36cpm Urinalysis:
(+) abdominal tenderness Fever Abdominal circumference: Increase WBC
Facial swelling 56.5cm Increase RBC
2.Membranous (+) hypertension Can be rule out with low C3 Periorbital edema (+) Erythematous Papular
Glomerulopathy (+) edema Vomiting Rash Low C3 - 195
(+) Facial swelling
(+) Periorbital edema Unremarkable KUB
3.Henoch-Schonlein (+) hypertension Rule out with low creatinine (+) Hypertrophic tonsils (Grade
Purpura Nephritis (+) edema and normal BUN II)
(+) previous streptococcal (+) Submandibular and anterior
infection cervical lymphadenopathy
(+) erythematous papular (+) Globular abdomen
rash at the lower extremities (+) Direct tenderness on the
(+) abdominal tenderness Left lower abdomen
(+) fever (+) Bilateral CVA tenderness
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Acute Post-Streptococcal
Glomerulonephritis
• Edema
• facial swelling and periorbital edema noted starting 3 days PTC • APSGN is one of the most common causes
• Hypertension of gross hematuria in children
• PE: blood pressure was 130/100 mmHg • Evidence of prior streptococcal infection
• ASO titer: 400 IU/ml
• “Tea-colored” urine • History
• UA upon admission: RBC: 35-40/HPF
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6/9/2018
Pathogenesis
Strep Pharyngitis
Anti-streptococcal
Ab formation (M12)
in situ immune
complex formation
formation of Ab-Ag
deposits on the
epithelial side of the
GBM
complement
activation
Subepithelial deposits
“Humps”
Pathogenesis
Glomerular
infiltration by
inflammatory
cells
decrease basement
membrane permeability
reduced glomerular
surface area
reduced GFR
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6/9/2018
Clinical Course
Progression
Clinical Course
Complications
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• Hematuria
• Edema • Edema
• facial swelling and periorbital edema noted starting 3 days PTC
• Hypertension • Hypertension
• Cerebral Symptoms • PE: blood pressure was 130/100 mmHg
• Oligoanuria • “Tea-colored” urine
• Cardiopulmonary • UA upon admission: RBC: 35-40/HPF
• Anemia
• Renal insufficiency
Management
Diagnostic
Diagnostic
• Anti-Streptolysin O Titer
• Urinalysis • to confirm previous strep infection
• to monitor hematuria, proteinuria, pyuria • KUB ultrasound
• CBC with Platelet count • to evaluate for GUT structure
• to evaluate for dilutional anemia or systemic infection
• C3
• Serum BUN and Serum Creatinine • to evaluate for hypocomplementenemia
• to evaluate for azotemia
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6/9/2018
Hemoglobin 96 Low
Differential Count
Basophils 0.01
• CBC, Urinalysis, BUN, creatinine, ASO titers, C3 and KUB
Monocytes 0.04
ultrasound were requested upon consult
• Urinalysis was repeated on day 1 hospital admisison Platelet Count 256
MCV 82.6
MCHC 326
RDW 12.6
KUB result
BUN, Creatinine, C3 and ASO
Both kidneys have homogenous parenchymal echogenicity.
titers
Right kidney measures 8.0x3.6cm
(normal length for age = 6.32 to 8.12cm) with parenchymal thickness of 0.7cm
07/04/2017 Interpretation
While the left kidney measures 8.5cmx4.3cm (normal length for
BUN (Blood Urea Nitrogen) 5.2 mmol/L Normal age = 6.72 to 8.56cm) with parenchymal thickness of 0.9cm .
No caliectasia or renal lithiasis seen.
Creatinine 47.5 umol/L Low
Urinalysis
Urinalysis 07/05/2017 07/06/2017
Color Yellow Light Yellow Therapeutic
Character Cloudy Slightly Cloudy
Specific Gravity 1.020 1.015
• Antibiotic Therapy to limit spread of
Ph 6.0 6.0 nephritogenic organisms
Albumin +1 Negative • Penicillin for 10 days
Sugar Negative Negative • Diuretics for edema
WBC 30-35/HPF 1-2/HPF • Furosemide IV
RBC 40-45/HPF 40-45/HPF • Antihypertensives
Bacteria +1 FEW
• ACE inhibitors
• Calcium Channel Blockers
Mucus Threads +3
• Vasodilators
Casts: White Cell 1-2/LPF
(Plus)
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Prognosis Resolution
CRITICAL
APPRAISAL
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CLINICAL QUESTION
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ASSESSING ASSESSING
APPLICABILITY APPLICABILITY
1. Are there biologic issues that may
affect applicability of treatment? 2. Are there socio-economic issues
affecting applicability of treatment?
There are no socio-economic issues that may affect the
applicability of the treatment since the antibiotic regimen
used in the study is widely available here in the Philippines.
From mims.com:
•Nifedipine tab/cap: 100’s
•Captopril tab: 100’s
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6/9/2018
INDIVIDUALIZING THE
RESULTS
Are the results beneficial to your patients worth the
harm and costs?
2
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6/9/2018
of open fractures.
General Data
Chief Complaint
• C.B.
• 15 year old
• Male Wound, Right foot
• Catholic
• Filipino
• Dasmariñas, Cavite
2 hours PTA:
Two hours
PTA
• He was using an electric grass cutter
• The blade hit his right foot
History of Present Illness • Blade was manually removed
• Consulted at a local clinic
• Wound care done
• Consulted at our institution
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6/9/2018
Review of Systems
SYSTEM
Personal and Social History General: (-) weakness, (-) loss of appetite, (-) fever, (-) weight loss, (-) easy
fatigability
•Works as a Grass cutter in the Integument: (-) wound, (-) rashes, (-) erythema, (-) pallor, (-) clubbing of nails, (-)
hyperpigmentation, (-) hypopigmentation, (-) mass
orchard in a golf field club
• Non-smoker and non-alcoholic beverage drinker Head and Neck: (-) stiffness, (-) dizziness, (-) headache, (-) swelling, (-) distention of
veins, (-) mass
•Denies of any use of illicit drugs Eyes: (-) pain, (-) inecteric sclera, (-) redness, (-) corrective lenses, (-)
•Lives with mother and father with 7 discharge, (-) blurring of vision
other siblings in a kubo style house Ears: (-) otalgia, (-) vertigo, (-) tinnitus, (-) hearing loss
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General Survey
• Came in ambulating
• Awake, conscious, coherent
Physical Examination • Not in cardiorespiratory distress
• Looks his chronological age of 15 years old
Regional Examination
Vital Signs
SYSTEMS Findings
• BP =
SHEENT (-) pallor, jaundice; anicteric sclerae, pink
100/60mmHg • Wt = 30 kg
palpebral conjunctiva; (-) CLADs
• HR = 84bpm • Ht = 131 cm Chest/Lungs Clear breath sounds, symmetrical chest
• BMI = 17.48 expansion
• PR = 84bpm kg/m2 Heart Normal rate and regular rhythm, (-) murmur
• RR = 18cpm Abdomen Soft, flat, nontender
• T = 36.90C
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6/9/2018
Neurologic CN FINDINGS
(+) Not assessed
• Mental Status Examination
He is awake and conscious and is (+) (+) Direct and Consensual light reflex
able to interact with examiner and III, EOM intact, symmetrical palpebral fissure,
recognize faces and respond to
eyes IV, VI aligned, (-) nystagmus As observed
touch.
(+) Good masseter contraction,
intact sensation on light touch
CN FINDINGS
VII Good facial movements and tone, CN FINDINGS
(-) Facial asymmetry; the patient (-) Atrophy of SCM and
was able to shut his eyes tightly
XI Trapezius
muscle
VIII Intact gross hearing Tongue in midline
XII
IX, X Symmetrical palate, uvula is in the (-) Atrophy (-)
fasciculations, (-)
midline, no hoarseness of voice asymmetry
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Motor System
Cerebellar Exam
Not done. Not done
Reflexes Meningeals
All of the reflexes are intact. The tests for passive neck flexion, Kernig’s,
There is no primitive reflex noted. and
Brudzinski are all negative.
Sensory Testing
100% on both upper and lower extremities
Management at the ER
Primary Impression •History and Physical Examination
•Wound dressing
Incised wound, Right Foot; R/O •Complete Blood Count
At the
fracture ER
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Laboratory Results
OPEN FRACTURES
Discussion
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Gustilo Classification
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TYPE II
Wound 1 – 10 cm
Energy Moderate Energy
Soft Tissue Moderate
Contamination Moderate
Fracture Pattern Moderate comminution
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TYPE IIIC
• ANTIBIOTIC THERAPY
First Generation Cephalosporin + Aminoglycoside + Penicillin E.g
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MANAGEMENT
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Day 1
Subjective Objective Assessment Plan
(+) pain on affected Stable Vital Signs Open Fracture Type Patient is for
foot IIIA, Undisplaced, discharge:
Course in the wards 1st metatarsal right;
S/P Wound
Home medications:
1. Cefuroxime (50
debridement and mg) - 1 capsule 3
suturing times a day for 7
days
2. Ibuprofen (40
mg) - 1 capsule 3
times a day for 7
days
Cefuroxime Cefuroxime
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Ibuprofen Ibuprofen
References
• Cross, W. & Swiontkowski, M. (2008) Treatment principles in the
management of open fractures. Retrieved December 11, 2017 from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740354/
• Murphy, A. & Hacking, C. Gustilo Anderson classification. Retrieved
December 11, 2017 from https://radiopaedia.org/articles/gustilo-
anderson-classification
• Canon, J. & Rasmusen, T. (2017) Severe extremity injury in the adult patient.
Retrieved December 11, 2017 from https://www.uptodate.com/contents/severe-
extremity-injury-in-the-adult-
patient?source=machineLearning&search=gustilo&selectedTitle=1~3§i
onRank=1&anchor=H151204170#H151204170
6/9/2018
Objectives
● To discuss the following:
CLINICAL MANAGEMENT ● a.) clinical
● b.) psychosocial
CONFERENCE ● c.) health system issues of the case (identify missed opportunities
for care and suggest ways to improve care processes
ENT JANUARY 1-15 ROTATORS ● 1. Discuss and correlate clinical presentation with pathophysiologic
mechanism and propose individualized diagnostic and therapeutic
interventions based on basic and clinical sciences
BANTILAN | CANUTO | DELA CRUZ | FORTUNO | GABORNO | IGNACIO | ● 2. Discuss the patient’s ability to comply with the proposed
LU| MALIMBAN | NEYRA | QUINTO | SUPILLO treatment and explore barriers to such compliance
● 3. Discuss the health system issues that influence the quality and safety
of care of the patient.
JANUARY 10, 2018
General Data
• Alice
• 25 year old female
• Chief Complaint:
CLINICAL APPROACH Severe headache
Scenario
History of Present Illness
• Patient arrived early morning
• 6 days prior to consult • Did not know what exactly what to do or who to see
Severe headache located on the forehead (first time in hospital)
• Everybody looked like they were in a hurry and they did not look
Colds, 6 day duration very friendly. Some of them looked as frightened as I was.
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DIFFERENTIAL DIAGNOSES
Rule In Rule Out
Influenza (+) Headache on the forehead Body malaise, joint pains and fever
(+) Colds usually accompanies the headache Rule In Rule Out
Migraine (+) Headache on the forehead Duration of headache (6 days) Brain Cancer (+) Headache on the forehead Patient’s Age
Associated with colds (+) Family history of brain cancer Cannot be totally ruled out
• Etiology
VIRAL
Bacterial infection Secretion Stagnate
BACTERIAL
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DIAGNOSTICS THERAPEUTICS
• PHYSICAL EXAMINATION NON-PHARMACOLOGICAL
• ENDOSCOPIC EVALUATION • Bed rest
• IMAGING STUDIES • Increase oral fluid intake
X-RAY OF THE PARANASAL SINUSES
CT SCAN
MRI PHARMACOLOGICAL
• LABORATORY STUDIES (+) NaCl Nasal Spray, 2-3 sprays on each nostril TID x 7days
CBC (+) Phenylpropanolamine HCl + Chlorphenamine
Maleate + Paracetamol Tablet, 1 tablet Q6 for 5 days
Poverty
Unemployment
(+) Other sickness in the family
PSYCHOSOCIAL APPROACH
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General Objectives
Conference: “Go on! Leave me At the end of this 1 hour session, the clinical
clerks should be able to recognize, clinically
breathless!” diagnose and manage a patient with pleural
effusion 100% of the time, at all possible
settings and circumstances.
FRANCIA · LU · MALIMBAN · RAKSHAM
Specific Objectives
General Data
To gather pertinent information through complete
history and thorough physical examination.
MC
To formulate all possible differential
diagnoses based on history and PE. 55 year old, Female
To discuss a complete plan of management with Married, Filipino, Roman Catholic
diagnostics, therapeutics and supportive Born on November 7, 1962 at Negros
regimen for the patient.
Oriental Currently residing at Taguig City
Admitted for the first time at DLSUMC on Feb
15, 2018 at 1:30 PM
Chief Complaint
History of Present Illness
“Cough” 7 weeks PTA
(+) Productive cough with whitish phlegm and clear
nasal discharge
(+) difficulty of breathing and easy fatigability
Consult was done
Rx: Dextromethorphan + Phenylephrine
+ Paracetamol (Tuseran)
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6/9/2018
Hyperthyroidism (2017), Rx: Methimazole (+) HPN, DM, Prostate Ca – paternal side
Cholelithiasis (2017) – no intervention yet (+) PTB exposure – husband ongoing 6
Allergies to dust and smoke months treatment; continuation phase
(-) Asthma, DM, HPN, Heart Disease, PTB, (-) Asthma, allergies, heart disease
cancer, previous surgeries
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Heart Abdomen
Inspection: (-) precordial bulge; PMI at the 5th ICS LMCL Inspection: Flat (-) scars (-) visible veins or pulsations
Auscultation: normoactive bowel sounds at 9/min, (-) bruit
Palpation: Apex beat at the 5th ICS LMCL, no heaves no Percussion: Tympanitic in all quadrants
thrills
Palpation: (-) tenderness (-) mass (-) organomegaly
Extremities Neurologic
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6/9/2018
Primary Impression:
Tuberculous Pleural Effusion, Left;
Hyperthyroidism in Euthyroid DIFFERENTIAL DIAGNOSES
State; Cholelithiasis
Differential Diagnosis
Transudative Pleural Effusion Exudative Pleural Effusion
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Light’s Criteria
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CHEST AP
Hospital Day 2 (2/17/18)
RECLINED PORTABLE
Problem Findings Assessment Plan (2/17/2018)
CHEST PAIN Serosanguinous Pleural Tuberculous For 12-Lead ECG
fluid-1550cc Pleural Effusion, ISDN 5mg tablet sublingual
O2 SAT- 98-99% Left s/p Start Dolcet mini 1 tab every
Decreased breath Ultrasound-guided 8 hours after meals
sounds- Thoracentesis Repeat chest x-ray
Mid to base lung
for ANA titer
Right shoulder pain
MICROSCOPIC EXAMINATION: Smears and cell blocks show several malignant cells seen singly and in
Parameter Released: 2/19/18
clusters, characterized by medium to large, round to ovoid pleomorphic generally vesicular nuclei with
TSH titer fine to coarse chromatin pattern and visible nucleoli.
TSH 3.61 uIU/ml Cytoplasm is scant to adequate and amphophilic, vacuolated or clear.
Cell blocks, in addition show the same malignant cells lining abortive and well formed glandular structures.
These are seen together with several mesothelial cells, histiocytes, lymphocytes and neutrophils on a
background of several red blood cells and amorphous material.
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No absolute contraindications
Relative contraindication: coagulopathy, thrombocytopenia
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6/9/2018
Pleurodesis
THANK YOU!
Indications/requirements
Daily output of a drainage catheter <150mL Full
expansion of the lung on chest radiograph
Complications
Fever
Pain
Nausea
Respiratory
failure Death
1
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General Objectives
Chief Complaint
“Burn”
Primary Survey
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6/9/2018
Airway Breathing
Assessment Assessment
• (+) singed nasal hair • Symmetric chest expansion
• (-) obstruction
• No hoarseness
• (-) blood per orem
• No stridor
• (-) sooty phlegm
• RR : 25cpm
• (-) foreign bodies
• O2 Sat: 99%
Intervention
• Hooked to O2 support via nasal cannula at 3 lpm Intervention
• None
Circulation Deficit/Disability
Asessment
• BP: 180/100mmHg
Assessment
• HR: 89cpm
(+) GCS 14 (E3, V4, M6)
• Normal rate, regular rhythm no murmurs (+) sensory, motor and CN were not assessed
• Full equal peripheral pulses
Intervention
(+) None
Intervention
• None
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Exposure Fluids
Assessment
Assessment
(+) Flame burns 30% BSA, Deep partial to (+) Flame burns 30% BSA, Deep partial to full
full thickness bilateral lower extremities and left thickness bilateral lower extremities and left arm
arm (+) Estimated Body Weight: 80kg
Intervention
(+) Fast Drip PLR 1L
Intervention
(+) Removed patient’s clothes and (+) Regulate IVF:
dressed her in hospital gown #1 PLR 1L x 340cc/hr for 7 hours
(+) Wound dressing #2 PLR 1L x 340cc/hr for 7 hours
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6/9/2018
SHEENT
Chest and Lungs
(+) Skin: The skin is moist, smooth texture, with good
capillary refill, no cyanosis, pallor, jaundice or rash, noted. Inspection: (-) Chest deformities (-) retractions (-) use
(+) Head: Head is normocephalic and symmetrical with gray of accessory muscles; AP:T=1:2
hair evenly distributed.
(+) Eyes: Pupils 3mm equal and briskly reactive to light,
EOMs full and equal at all 6 cardinal directions of gaze, no Palpation: (+) Symmetrical chest expansion
excessive lacrimation.
(+) Ears: No lesion, mass, or deformity of Pinna or peri- Percussion: (+) Resonant in all lung fields
auricular area, external ear canal opening patent.
(+) Nose: Patent; no septal deviations. (-) discharge
(+) Throat: (-) cervical lymphadenopathies (-) thyroid gland Auscultation: Clear Breath sounds
not palpable (+) trachea midline (-) neck vein distention. (-) crackles (-) wheezes (-) rhonchi
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Heart Abdomen
th
Inspection: (-) precordial bulge; PMI at the 5 Inspection: Flat (-) scars (-) visible veins or pulsations
ICS LMCL
Auscultation: normoactive bowel sounds at
th 9/min, (-) bruit
Palpation: Apex beat at the 5 ICS LMCL,
no heaves no thrills Percussion: Tympanitic in all quadrants
Palpation: (-) tenderness (-) mass (-) organomegaly
Ausculatation: Normal rate at 89 bpm, regular
rhythm, S1>S2 at the apex, S1<S2 at the base, no
S3 or S4, no murmurs.
Extremities Neurologic
(+) (+)Swelling, (+)Redness,
(+)tenderness, (+)warm and GCS 14 (E3, V4, M6)
(+)edematous bilateral lower extremities
and left arm
(+) (-)Limitation of ROM
(+) Full and equal peripheral pulses
Primary Impression:
Flame burns 30% BSA Deep partial to full thickness bilateral lower
extremities and Left arm
COURSE IN THE ER
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Laboratory
CBC
Hemoglobin – 151
Sodium – 136
Hematocrit - 0.46
Potassium – 3.7
WBC – 14.9H
Creatinine – 83.6
RBC – 5.8
Segmenters – 0.49L
Lymphocytes – 0.46H CHEST AP VIEW
Eosinophils – 0.01L -unremarkable
Basophils – 0.00
Monocytes – 0.04 COURSE IN THE WARDS
Platelets - 296
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FINAL DIAGNOSIS
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Overview of burn
management injury
RESUSCITATIVE PERIOD DEFINITIVE PERIOD
(First 48 hours) (>48 hours)
• Assessment of burn • Excision and Grafting
injury • Control of infection
• Classification of burn • Nutrition
CASE DISCUSSION injury • Rehabilitation
• Criteria for admission • Prevention and
• Initial ER management Management
Fluid Resuscitation Complication
Wound dressing
Monitoring
ETIOLOGY OF BURNS
FLAME BURN - direct contact with fire
FLASH BURN - intense heat for a brief period of time
SCALD BURN - contact with hot liquids
CONTACT BURN - contact with hot objects (metal, plastic, glass etc.)
CHEMICAL BURN
BURNS a. ACID BURNS: self-limiting
b. ALKALI BURNS: continue to dissolve skin until neutralized
ELECTRICAL BURN
High Voltage - >1,000 volts
Low Voltage - <1,000 volts
RADIATION BURN - laboratory accidents, x-ray machines, etc.
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CLASSIFICATION OF BURNS
Fourth Degree Burn 1st degree burn 2nd degree burn 3rd degree burn 4th degree
(DEPTH)
Description
Epidermal
Tissue damage restricted to
Partial-Thickness Full thickness Burn
Involves the epidermis and Involves epidermis, dermis Involves bone, muscles and
epidermis and upper part of the dermis and subcutaneous tissue tendons
dermis
Cause Flash flame, ultraviolet Contact with hot liquids or Contact with hot, liquids or Prolonged contact with flame,
(sunburn) solids, flash flame or direct solids, flame, chemical, electrical
flame, UV electrical
Surface appearance Dry, no blisters, no or Moist blebs, blisters Dry with leathery eschar Same as 3rd degree possibly
minimal edema until debridement with seen bone, muscle and
Charred vessels are tendon
visible
Color Erythematous Mottled white to pink, cherry Mixed white, waxy; dark, Same as 3rd degree
red khaki, charred
Sensation Painful Very painful Decreased sensation intact Little or no pain (nerves are
deep –pressure sensation destroyed)
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ESTIMATIN
G EXTENT
OF BURN
INJURY
Overview of burn
management injury
RESUSCITATIVE PERIOD DEFINITIVE PERIOD
(First 48 hours) (>48 hours)
• Assessment of burn • Excision and Grafting
injury • Control of infection
• Classification of burn • Nutrition
injury • Rehabilitation
• Criteria for admission • Complication
• Initial ER
management Fluid
Resuscitation Wound
dressing Monitoring
Initial ER Management
• Primary Survey • Secondary Survey
A-irway • A -llergies
B-reathing • M –edications/Tetanus
Immunization
C-irculation
• P – revious Illness
D-isability/Deficit
• L –ast meal or drink
E-xposure
• E – vents preceding the injury
F-luid Resuscitation
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WOUND DRESSING
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Yesterday
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THANK YOU!