DEPARTMENT OF NEUROSCIENCES
Philippine General Hospital
University of the Philippines Manila
The Health Sciences Center
Taft Avenue, Ermita, Manila
“PHIC Accredited Health Care Provider”
INCOMING Notes
October 19, 2009
9th Hospital Day
Patient
Date of Admission
Location
Case Number
NAVARRO, NELIA
October 10, 2009
NICU 04
3497029
Service
Service Senior
RIC
SIC
A
DR. FABIANA
DR. PALISOC
CLERK MIKAELA NIKKOLA JARA
GENERAL DATA
Pt is a 65/F, R-handed, non smoker, non-alcoholic beverage drinker with no known other illness.
CHIEF COMPLAINT
Inability to open mouth
HISTORY OF PRESENT ILLNESS
3 weeks PTA, patient hit her left big toe against the wall of their bathroom. It eventually became swollen and painful after a few hours.
2 weeks PTA, patient can’t help wading on the flood with her open wound still swollen. She took amoxicillin 500 mg QID for 5 days which afforded very minimal relief.
5 days PTA, patient noted yellowish pus fluid oozing out of her wound.
3 days PTA, patient began having difficulties in speaking, opening her mouth and swallowing even her own saliva which persisted for two days.
On the day of admission, patient had (+)trismus, (+)risus sardonicus, dysphagia and neck rigidity, hence, present admission.
REVIEW OF SYSTEMS
(-) fever
(-) easy fatigability
(-) cold and cough
(-) nausea and vomiting
(+)dysphagia
(+) headache
(-) PND
(-) chest pain
(-) dyspnea
(-) palpitations
(-) abdominal pain
(-) oliguria
(-) melena
(+)tremors
PAST MEDICAL HISTORY
As above. no hospitalizations
FAMILY MEDICAL HISTORY
(-) DM, PTB, heart, BA
(+) HPN, stroke
PERSONAL/SOCIAL HISTORY
Non-smoker, non-alcoholic beverage drinker
PHYSICAL EXAMINATION
General Survey: eyes covered with gauze, able to follow simple commands, able to move her extremities
Vital Signs: BP: 160/90 HR: 90 RR: 28 Temperature: afebrile
HEENT: pink conjunctivae, anicteric sclerae, supple neck, (-) CLAD, (-) TPC, (-) NVE, (-) carotid bruit
Chest / Lungs: Equal chest expansion, clear breath sounds, (+) rhonchi, upper lung fields, (-)retractions
CVS: Adynamic precordium, distinct heart sounds, normal rate, regular rhythm, (-) murmurs
Abdomen: Flabby, NABS, soft, nontender, (-) organomegaly/masses
Skin / Extremities: Full, equal pulses, CRT< 2 seconds, (-) cyanosis/edema/clubbing
Neurologic examination:
GCS 15, awake, able to follow commands, oriented to 3 spheres
Pupils 2-3/2-3 EBRTL, (-) visual field cuts to threat, VA not assessed,
Full EOMS
(+) corneal reflex
(+)difficulty opening mouth
No Facial Asymmetry
Good hearing
(+) dysphagia
Good gag reflex
Tongue midline
Motor exam: 5/5 on all extremities
Sensory: 100% on all extremities DTR’s: ++ all extremities (+) nuchal rigidity (-) clonus/Babinski/nystagmus/abnormal sweat patterns
COURSE in the HOSPITAL
(10/10/09) Patient was seen at the ER. PE showed (+) lock jaw, (+) sardonic grin, (+) slight swollen left big toe, (+) neck rigidity, (-) lateralizing signs. Hemodynamically
stable. Assessment was tetanus. Referred to ORL for tracheostomy. Advised admission to NICU once there’s an available room. Given ATS 3000 IM, Tetaunus Ig 0.5
ml IM, Metronidazole, 500 mg/tab q 6 hours, Diazepam 5 g IVP q 4 hours, Ceftriaxone 11 gm IV q 12, Carbamazepine 200 mg/tab BID, Omeprazole 40 mg 1 tab OD,
and Paracetamol 500 mg/tab PRN for fever. Patient was maintained on MAP 110-130. Diagnostic tests were ordered. Oxgenated and placed in a dark quiet room.
(10/11/09) Patient was transferred to NICU Bed 4. Maintained on the above medications with additional Baclofen 10 mg/tab, 1 tab TID.
(10/12/09) There were episodes of hypotension which were managed with PNSS 300 cc bolus and dopamine drip. Noted dark-colored urine. Bactidol q 8 for oral
hygiene was added to the above medications. Patient was started on a 2500 kcal/dat.
(10/13/09) Noted worsening muscle spasm. Added morphine 5 mg very slow IV q 8 hours to the medications. Code called, revived after ? minutes. Impression was
dysautonomia with bradycardic episodes, revived with strain ECG pattern.
(10/14/09) Leptospirosis was entertained on top of the impression of tetanus. Lepto MAT was ordered. Hypokalemia: given oral KCl 30 cc TID x 2 days. Started on
Heparin 50 units SC for DVT prophylaxis.
(10/15/09) Referred to Gen Med.
(10/16/09) Morphine discontinued. Referred to DENT and GS for evaluation of possible other sources of infection.
(10/17/09) Continued medications. Followed-up labs. Discontinued oral KCl.
(10/19/09) EEG, Chest X-ray, and Oblique left foot x-ray were done.
(10/21/09) Patient was febrile with 40 deg Celsius. Day 2 of no bowel movement. No hematuria. With episodes of hypotension even while on dopa drip. Advised to
start on Levetiracetam 500 mg/cap OD and Myonal 50 mg 1 tab TID. Tapering of carbamazepine and diazepam were started. Patient was referred for increased
duration of spasm, >20 seconds characterized as stiffness of neck and extremities. During this time, there was desaturation to 68-70% and hypotension 70/40.
Dopamine increased by 5 cc/hour until the BP maintained at 90/60 and was given diazepam. Gen Med Service noted thick blood-tinged secretions per ET and
beginning pressure ulcers and decubitus ulcer. They suggested for referral to IDS for opinion.
RESULTS OF DIAGNOSTICS/LABORATORY EXAMS
HEMATOLOGY
WBC
RBC
Hgb
Hct
Platelets
Neut %
Lymph %
Mono %
Eosino %
Baso %
BLOOD CHEM
Glucose
BUN
Creatinine
Sodium
Potassium
Chloride
Calcium
Magnesium
Phosphates
Total protein
Albumin
Globulin
AST (SGOT)
ALT (SGPT)
Alk phos
HDL
Cholesterol
LDL
TG
Normal
4-11x109/L
4-6x109/L
120180g/L
0.3700.540%
150450x109/L
0.5-0.7
0.2-0.5
0.02-0.09
0.0-0.06
0.0-0.02
10/13
13.5
3.45
99
10/15
13.99
3.75
105
10/19
17.7
2.85
85
0.309
0.345
0.255
110
279
249
0.633
0.99
0.64
0.003
0.001
0.867
0.072
0.057
0.003
0.001
0.909
0.047
0.040
0.004
0.000
10/10
7.84
6.54
101
148
3.4
109
10/12
10/14
10/15
10/16
10/17
10/19
10/19
10/21
98
143
4.0
3.30
65
144
2.5
5.69
79
143
3.1
94
142
4.2
88
140
4.2
80
138
3.5
84
97
138
3.5
2.54
1.0
1.97
0.75
20
18
39
27
55
28
36
39
97
34
32
(10/10/09) Creatinine Kinase Total 357
(10/12/09) CK-MB 18.8
(10/14/09) Troponin I Quanti 0.361
(10/15/09) Glycosylated Hgb 6.0
ABG
(10/13/09): pH 7.368 pCO2 50.8 pO2 81.6 Temp 37.8 degreesC FI02 100% BP 758.2 mmHg HCO3 29.2mmol/L O2Sat 95.6% BE 3.7 mmol/L TCO2 30.8mmol/L O2CT
15.0vol% SBC 27.7 mmol/L
(10/14/09): pH 7.286 pCO2 82.9 pO2 362.6 Hct 33.6 Temp 37.0 degrees C FI02 100% BP 755.8 mmHg HCO3 39.4mmol/L O2Sat 99.7% BE 10.1 mmol/L TCO2
42.0mmol/L O2CT 17.5vol% SBC 34.0 mmol/L
PT
CONTROL
10/11/09
13.0
PATIENT’S VALUE
12.3
% ACTIVITY
INR
1.00
1.18
PTT
CONTROL
PATIENT’S
VALUE
10/11/09
37.4
39.1
URINALYSIS
(10/11/09) Dark Yellow Slightly Hazy SG:1.030 pH 6.0 Sugar:2+ Protein: 2+ RBC:0-1/hpf WBC: 2-5/hpf Epith: Rare Bacteria: Few Mucus Thread: 1+ Crystals: Negative
Cast: Negative Bilirubin: Negative Myoglobin: Negative Leucocytes: Trace Nitrite: Negative Hemoglobin: 2+ Urobilinogen: Normal Ketone: Trace
(10/18/09) (-) Myoglobin
Blood CS
(10/11/09): No Growth After 2 Days
(10/16/09): No growth after 5 days
Blood AB
(10/17/09): No growth after 2 days of incubation
(10/20/09): No growth after 5 days of incubation
Sputum GS
(10/12/09) PMN <10 SQEPITH: <10 Gram(-) Diplococci:0-2 Yeast Cells: none Hyphal elements: none Gram(+) Cocci in pairs: 0-1 in Chain:none Gram(+) bacilli:none
Gram(-) bacilli: none
Tracheal Aspirate Gram Stain
(10/12/09) PMN <10, Gram (+) cocci in pairs: 0-1 in chain: none, Gram (-) Bacilli: none, Gram(+) Bacilli: none, Yeast Cells: none, Gram (-) diplococcic: 0-2, Squamous
Epithelial Cells: <10. NO GROWTH AFTER 2 DAYS
(10/19/09) PMN>10 Sq epithelial cells < 10/lpf, gram (-) diplococci 1-3, (-) yeast cells/hyphal elements, gram (+) cocci in pairs 1-3 in chain none, gram (-) bacilli > 25,
gram (+) bacilli, none/oif
CHEST X-RAY
(10/10/09) Cardiomegaly with pulmonary congestion, pleural effusion, left, not ruled out
ECG
(10/10/09) Sinus tachycardia, normal axis, non-specific STT wave changes
(10/11/09) Regular sinus rhythm, normal axis, non-specific STT wave changes
(10/13/09) Sinus arrhythmia, normal axis, nonspecific STT wave changes
(10/14/09) Sinus tachycardia, normal axis, non-specific STT wave changes
(10/14/09) Sinus tachycardia, normal axis, non-specific STT wave changes, poor R wave progression
PRESENT WORKING IMPRESSION
TETANUS STAGE II
MEDICATIONS ON BOARD
Enoxaparin 0.4 SC OD
Metronidazole 500mg/tab q6
Diazepam 5g IVP q4hours
Ceftriaxone 1 gm IV q12
Carbamazepine 200 mg/tab BID
Omeprazole 40g 1 tab OD
Paracetamol 500mg/tab PRN for fever
Baclofen 10mg/tab, 1 tab TID
Bactidol q8 for oral hygiene
Heparin 5000 units SC for DVT Prophylaxis
OTHERS
Watchout for progression of spasms, profuse
sweating, peripheral vasoconstriction, cardiac
arrythmia, tachycardia, and hypotension.
AVOID LIGHT, AIR and SOUND STIMULATION at all
cost.
IVF: pNSS 1L x q16hrs
Monitoring:
CBG Q4
Maintain MAP 110-130
Elevate head at 30 degrees midline
Monitor VS, NVS Q1;
Strict I&O
For close watch
Fluid Challenge for BP<90/60, Reserve Dopamine
for BP unresponsive to Fluid Challenge
Prepared by: Clerk Mikaela Nikkola Jara