CASE PROTOCOL
This is the case of DE, a 46/F, married, Roman Catholic, born on December 1, 1971 in Tarlac,
residing in Sitio Paninaan Carangian, Tarlac Ciy, Tarlac and was admitted for the 1st time at
Bonggah Hospital on May 27,2018, 7:556PM.
Chief Complaint: Difficulty of breathing
Interval History:
Patient is a known case of CKD. One month prior to admission, patient was admitted for 9 days
in a government hospital in Tarlac for IJ reinsertion. She missed 3 consecutive dialysis sessions.
Upon discharged, she reported difficulty of breathing, orthopnea, easy fatigability and inability
to perform ADL.
History of Present Illness:
3 days prior to admission still with difficulty of breathing, palpitation, easy fatigability, orthopnea
and inability to perform activities of daily living, now with occurrence of d cough, with greenish
phlegm, unintentional weight loss (from 60kgs to 40kgs since?) poor appetite 2 tbsps/meal and
body weakness. There were no fever, chest pain, back pain, night sweating, etc. No consult done.
No medications taken.
Few hours prior to admission, due to the persistence of the above symptoms, she consulted at
our institution. Emergency hemodialysis was done with the following parameters: Dialyzer
HIPS15, UF 3.5L, Regular Heparin, 4 hours duration, HCO3 500ml/min. Due to the resolution of
dyspnea, she was sent home. However, at home above symptoms recurred, consulted again at
our institution, hence the admission.
Past Medical History
Known CKD since 2012, on maintenance hemodialysis 2x/week
Known Hypertensive since 2012
HBP: 170/120 mmHg
UBP: 120/80 mmHg
Urolithiasis, 2010 underwent unrecalled procedure
Allergic to chicken and egg yolk
Maintenace Medications:
Amlodipine 10mg/tab, 1 tab OD shifted to
Losartan 100mg/tab, 1 tab OD
FeSO4 2 tabs BID
CaCO3 500mg/tab, 1 tab TID
EPO 4,000 IU BID
No Diabetes mellitus, Bronchial asthma, Thyroid, Heart and Liver diseases, Cancer
Previous Admission: August 2017 at a local hospital in Tarlac, Anemia, s/p Blood Transfusion
Family History:
Hypertension, father
No Diabetes, Bronchial Asthma, Tuberculosis, Cancer
Personal/Social History:
Patient used to live in Malaysia since she was 23 years old and worked as a cashier in a bookstore.
She went back to our country last May, 2017. She is non-smoker and non-alcoholic beverage
drinker. No exposure to second hand smoke. She denies use of illicit drugs. Childhood
immunizations are uncertain. She received annual flu vaccine in Malaysia, last was unrecalled.
Review of Systems:
HEENT: (-) Blurring of vision, (-) Epistaxis, (-) Colds, (-) Tinnitus, (-) Dysphagia, (-) Odynohagia, (-)
Hoarseness, (-) Neck masses
Gastrointestinal: (-)nausea/vomiting, (-) LBM, (-) hematochezia
Genitourinary: (-) nocturia, (-) hematuria
Hematologic: (+) pallor, (-) easy bruising
Endocrine: (-) polydipsia, (-) polyuria, (-) polyphagia
Musculoskeletal: (-) Swelling of joints, (-) Joint pain, (-) Muscle cramps
Neurologic: (-) headache, (-) dizziness, (-) episodes of loss of balance
Physical Examination:
Vital signs: BP=90/70 mmHg
HR =120 bpm
RR =28 cpm
T=36.6 °C O2Sat=96%
General:
Skin: no active dermatoses, no jaundice
HEENT: Icteric sclerae, pale palpebral conjunctivae, no palpable cervical lymphadenopathies, no
tonsillopharyngeal congestion, with subclavian catheter, right, with distended jugular vein
Pulmonary: Symmetrical chest expansion, no retractions, crackles on left lung field
CVS: Adynamic precordium, PMI at 6th ICS LMCL, tachycardic, regular rhythm, no murmurs, soft
S1 and S2
Abdominal: Flabby, normoactive bowel sounds, tympanitic, soft, non tender
Extremities: Pale nailbeds, no cyanosis, no edema, Full and equal peripheral pulses
Neurologic: GCS 15 (E4V5M6), no neurologic deficit
Admitting Impression: Acute Pulmonary Congestion Secondary to Chronic Kidney Disease Secondary to
Hypertensive Nephrosclerosis, Anemia secondary, on Maintenance Hemodialysis; To consider Hospital
Acquired Pneumonia
Course in the Ward:
Upon admission, diagnostic tests done were CBC, 12L ECG and CXR. Heplock was inserted.
Ceftriaxone 2gm IV now then Q12, N-Acetylcysteine (Fluimucil) 600mg/tab to be dissolved in 50cc
water to be taken BID, Salbutamol+Ipratropium Bromide (Combivent) 1 neb Q6 and
Hydrocortisone 250mg IV now then 100mg IV Q8 were started. Limit OFI to 1 liter/day. Patient
was hooked to O2 at 2LPM via nasal cannula. Maintenance medications such as CaCo3
600mg/tab, 2 tablets TID, FeSO4 2 tablets BID were continued.
In the ward patient had episode/s of vomiting, Metoclopramide 10mg IV now then Q8 PRN for
vomiting was ordered.
On the 1st hospital day, still with recurrence of difficulty of breathing, cold-clammy skin, and with
O2 Sat of 86-88%,BP was 90-100/70-80mmHg, early dose of Hydrocortisone of 100mg was given
and increase frequency to Q6. Patient was also referred to a cardiologist regarding CXR findings
of Cardiomegaly. 2D Echo with color Doppler and chest ultrasound were suggested and carried
out. Results revealed pericardial effusion with tamponade. Emergency pericardiocentesis was
done. They were able to drain approximately 1.8L reddish fluid. She was transferred at the ICU
after the procedure. Repeat 12L ECG and CXR was ordered. Pericardial fluid analysis was sent to
laboratory for testing. Hold nebulization until further order.
On the 2nd hospital day, hemodialysis was done with the following parameters, duration of 4
hours, UF of 2 liters including flushing, Heparin free, Qb 200 and Qd 400. There was resolution of
difficulty of breathing, orthopnea and paroxysmal nocturnal dyspnea. She was for transfer to
regular room once hemodynamically. Repeat 2D echo with Doppler and respirometry was
ordered once to room. Hydrocortisone was decreased to 100mg IV Q8. Levocetirizine 5mg/tab,
1 tablet was also started for cough and throat itchiness.
On the 3rd hospital day, hemodialysis was done with the following parameters: UF 3L, Qb 200250ml/min, Qd 400-500 ml/min, Heparin free and Bicarbonate bath. Advise small frequent
feedings during hemodialysis. Nebulization was resumed. CXR post dialysis was ordered and CBC
in AM. Patient was then referred to infectious consultant due to the consideration of pericarditis.
On the 4th hospital day, possible repeat 2D echo, due to the resolution of symptoms, patient
opted to go home per request with the following medications: Cefpodoxime 200mg/cap, OD x 7
days, N-Acetylcysteine (Fluimucil) 600mg/tab to be dissolved in 50cc water to be taken BID,
Calcium carbonate 2 tabs TID, FeSO4 2 tabs BID and Levocetirizine 5mg/tab, 1 tab ODHS.
Laboratories and Imaging Results:
CBC May 27, 2018
TEST
WBC
NEUTRO
LYMPHO
MONO
EO
BASO
RBC
HGB
HCT
MCV
MCH
MCHC
PLT
RESULT
5.25
68.7
16.2
12.0
2.7
0.4
3.68
10.2
31.4
85.3
27.7
32.5
221
SI REFERENCE
UOM
M(4.23-9.07) F(3.98-10.04)
M (34-67.9) F (34-71.1)
M (21.8-53.1) F (19.3-51.7)
M (5.3-12.2) F (4.7-12.5)
M (0.7-0.8) F (0.7-5.8)
M (0.2-1.2) F (0.1-1.2)
M (4.63-6.08) F (3.93-5.55)
M (13.7-17.5) F (11.2-15.7)
M (40.1-51.0) F (34.1-44.9)
M (79.0-92.2) F (79.4-97.8)
M (25.7-32.2) F (25.6-32.2)
M (32.3-36.5) F (32.2-35.5)
150,000-400,000
X 10 ^ 3/uL
%
%
%
%
%
X 10 ^ 3/uL
g/dL
12L ECG
May 27, 2018
Sinus tachycardia, normal axis, low voltage complexes
Non specific ST T wave changes, poor r wave progression
To consider anterolateral wall ischemia
%
Fl
Pg
g/dl
X 10 ^ 3/uL
CXR
May 27, 2018
Pneumonia vs congestive changes, right mid to lower lung fields.
Cardomegaly.
Atheromatous aorta.
CXR
May 28, 2018
Repeat study as compared with the one done on 5/27/2018 shows both lungfields to be
essentially clear. Heart is enlarged. The rest of the visualized chest structures are unremarkable.
There is IJT in placed. Cardiomegaly.
12L ECG
May 28, 2018
Sinus tachycardia
NSSTT wave changes
Anterolateral wall ischemia
CHEST ULTRASOUND
May 28, 2018
Normal chest sonogram.
GRAM STAIN
May 28, 2018
SPECIMEN
RESULT
PERICARDIAL FLUID
No microorganism seen.
PMNs 1+
ACID FAST BACILLI
May 28, 2018
SPECIMEN
RESULT
METHOD
PERICARDIAL FLUID
NEGATIVE FOR ACID FAST BACILLI
ZIEHL0NEELSEN METHOD
2D ECHO
May 29, 2018
EF 48%
Concentric left ventricular hypertrophy with multi segmental wall motion abnormalities and
moderately depressed overall systolic function.
Dilated left atrium and right atrium.
Dilated right ventricle with systolic dysfunction visually, and signs of volume and pressure load.
Mild to moderate aortic regurgitation.
Moderate tricuspid regurgitation.
Pulmonic regurgitation.
Pericardial effusion as described without tamponade physiology.
Mild pulmonary arterial hypertension.
CBC May 30, 2018 (NOT DONE)
CXR
May 30, 2018
Follow up study after two days now shows the left hemidiaphragm and costophrenic sulcus are
obscured which may be due to fluid.
Heart is enlarged.
Atherosclerosis is seen in the thoracic aorta.
IJ Catheter is seen on the right.
Rest of the study is unchanged and unremarkable.
INSTRUCTIONS:
1. Explain why the DIAGNOSTIC TESTS WERE REQUESTED
2. Discuss BRIEFLY why the medications mentioned above were used. Why were they used
3.
In the management of a subclavian access, it is an integral part of its management is to
maintain asepsis to prevent catheter related infection. Since the advent of the use of alcohol,
there had been preparations shown to have significant antiseptic properties. Studies have
shown that a 70% solution acts best to eliminate a broader spectrum of harmful microorganisms
however, Why can’t we just use a 100% alcohol preparation instead?
a. Discuss why studies show that a 70% EtoH is better than a 100% EtoH.