General Data:

P.F.R.
71/M/M
San Juan, La Union
Born on 04/19/1949
Roman Catholic
Date of Admission: 1/20/2021
Chief Complaint:

Abdominal pain
History of Present Illness:

5 days PTA

(+) epigastric pain, continuous,

3 days PTA
burning, 5-6/10, Non radiating Few hours PTA
(+) > 10 episodes of coffee THOC to Bethany
ground vomitus – Admitted x 2 days.
Still with epigastric pain, No BM
(+) cough, with greenish
and flatus
sputum
- > tc Obstruction
(+)DOB
-> transferred into our
Consult at Bacnotan DH
institution for further eval and
–> admitted for 3 days
management.

-
Past Medical History Family Medical History
• No Hypertension • No Hypertension
• No Diabetes Mellitus
• No Cancer
• No Known cardiac disease
• No Bronchial Asthma • No Diabetes Mellitus
• No PTB • No PTB
• NO KNOWN CO-MORBIDS OR MAINTENANCE MEDICATIONS
• DENIES WEIGHT LOSS • No Bronchial Asthma
• DENIES CHANGES IN BOWEL OR BLADDER HABITS PRIOR TO
ADMISSION

Personal / Social History

• PREVIOUS SURGERY: S/P EX LAP FOR STAB WOUND (1980’S)

• Smoker: 3 sticks/day
• Alcoholic beverage drinker
Physical Examination
• GS: Awake, in mild respiratory distress, speaks in phrases, afebrile, GCS 15
• VS: BP: 140/90 CR: 94 RR: 24 T: 36.7 SPO2: 95%
• SKIN: No pallor, no jaundice, no cyanosis
• HEENT: Anicteric Sclera, Pink palpebral conjunctiva
• C/L: tachypneic, SCWE, crackles, bilateral LF
• HEART: AP, regular rhythm, no murmurs
• ABD: (+) surgical scar, Paramedian; sl. distended,
tympanitic, soft, direct tenderness on the epigastric area
• DRE: GST, smooth walls, no mass palpated, black fecal
materials on tactating finger
• EXT: FEPP, CRT< 2 sec
Mortality – Non Operative Day of Admission
Assessment Diagnostics Therapeutics
01/20/20 VS CBC, ABO typing, PT INR Admit to Med annex – ISOL
9:50 pm BP 140/90 BUN, Crea NPO
CR 84 Serum Electrolytes IVF: PLRS 1L x 12
RR 20 AST/ALT, TPAG Meds
T 36.7 Amylase/Lipase 1) Omeprazole
SPO2 9% COVID 19 RTPCR OPS/NPS 2) Cefoxitin
Ht 175 cm CXR-PA 3) Metoclopromide
Est Wt 70 kg Flat Plate Abdomen – supine and upright - NGT and monitor output
BMI 23 12 L ECG - IFC and
-refer to IM Pulmo
-refer to IM Gastro
IM-ER notes
• Start Omeprazole Drip: Omeprazole
80mg + 90cc PNSS TRF 10 hrs
• Sucralfate 10mg/tab 1 tab q6
• Piperacillin Tazobactam 4.5g IV q6
• Metronidazole 500mg IV q8
• Shift IVF to D5LR 1L x 8
Mortality – Non Operative HD 1
Assessment Diagnostics Therapeutics
01/21/2021 (HD1) CBC Bun = 28.6 NPO
5:20 AM Hgb = 119 Crea = 162 IVF: PNSS 1L x 12
Hct = 0.39 TP = 65.34 Meds
VS
BP 130-140/70-80
WBC = 15.40 A = 28.39 1) Piperacillin Tazobactam 4.5g IV q6
HR 80-105
PC = 238 G = 36.95 Start Ciprofloxacin 400mg IV now then
RR 18-20
N = 74.4 A/G = 0.77 200mg IV q12
T 36.1-37
L = 18.2 AST = 18.33 Continue Omeprazole Drip
SPO2 97-99%
M = 5.1 ALT = 9.04
Input 2190 E = 2.1 Amylase = 310.96 -still For Whole Abdomen CT scan with
UO 1550 O positive Lipase = 360 Triple Contrast scheduling
(+) flatus (+) BM PT 13.8 Na = 146.4
(melena) INR 1.17 K = 4.60 -refer to IM Nephro for clearance
COVID 19 Ag = Mg = 1.00 CBG monitoring q8
Abdomen: flat, , non- Negative ALP = 63.02 Maintain NGT and IFC
distended
soft, direct tenderness
on the epigastric area
NGT output – bilious –
minimal
CHEST AP Flat Plate Abdomen
Suboptimal study
Mortality – Non Operative HD 2 - 4
Assessment Diagnostics Therapeutics
IM Nephro Repeat CBC, BUN, Crea tomorrow -suggest to use iso-osmolar contrast
- Moderate risk for (01/22/21) - Start NAC 600mg/tab 2 tab BID
contrast induced before, on the day and 1 day after CT
nephropathy Repeat Crea 72 hrs post CT scan scan
- Increase IVF to 125cc/hr with
congestion precaution
01/22/2021 (HD2) Hgb = 117 May have sips of water
9AM Hct = 0.39 VS
D5LR 1L x 8
WBC = 32.30 BP 110-130/70-80
1) Piperacillin Tazobactam 4.5g IV q6
(+) BM (+) flatus N = 80.9 HR 84-105
2) Ciprofloxacin 200mg IV q12
(+) abdominal pain, L = 15.0 RR 19-20
epigastric area M = 4.0 T 36.1-37
(-) Melena / Hematochezia E = 0.1 SPO2 95%
Abdomen: flat, non
distended, tenderness on PC = 228 Input 2995
epigastric area BUN 22.7 UO 1550
Crea 144
For repeat FPA in AM
 CHEST AP FPA
01/25/2020 01/25/2020

CHEST AP

Persistence of reticulohazed and patchy opacities on

both lungs with regression on the right and progression
on the left. This is ascribed to Pneumonia

Aorta is sclerotic
Mortality – Non Operative HD 5 -7
Assessment Diagnostics Therapeutics
01/26/2021 (HD6) Hgb = 101 VS May have SOFT to DAT
7:28AM Hct – 0.34 PLRS 1L x 12
BP 100-
(-) Fever WBC 23.03 110/70-80 1) Piperacillin Tazobactam (d5)
(+)Flatus PC = 274 2) Ciprofloxacin 200mg IV (d5)
HR 88-106
(+) BM 1x N = 78.2 3) Continue Omeprazole Drip
(-) abdominal pain L = 15.6 RR 19-20
(-) nausea/vomiting M = 5.2 T 36.1-37
Abdomen flat, soft, tympanitic, E = 0.5 SPO2 9%
localized tenderness on BUN = 17.5 Input 1900
epigastric area Crea = 136
UO 1590

01/27/2021 (HD7) For WAB CT with Triple contrast (Scheduled on Feb 2, Soft diet with SAP
9AM 2021 9am) IVF Same rate
Repeat Amylase and Lipase Continue Omeprazole
(+) BM 1x (+) flatus (+)Melena Repeat FPA supine and upright IM notes– COVID RTPCR Negative 2x - May
(+) Coffee ground vomitus 1 x Hgb = 115 transout to regular ward
Hct – 0.37
Abdomen: Direct tenderness WBC 24.07 (N = 50.50 / L = 47.20) Still for co-management with IM Nephro, Pulmo
on epigastric area, LUQ PC = 363 and Gastro
Crea 140.0 TOS to Surgery ward once with Pulmo/Gastro/IDS
Na 142.8 notes
K 4.11
Mortality – Non Operative HD 8 - 9
Assessment Diagnostics Therapeutics
01/28/2021 (HD8) VS
NPO Temporarily
Re-insert NGT open to BSB
(+)vomiting 1 X (coffee ground) BP 90-110/60-80 IVF: PLRS 1L x 12h
(+)BM (+)Flatus HR 91-124 Refer back for EGD scheduling c/o IM Gastro
(+)Dyspnea RR 24-32 Continue current medications
Abdomen: soft, tender on LUQ T 36.5-37,1
and epigastric area SPO2 91-98%
01/29/2021 (HD9) Input 2900 Maintain NPO, may wet lips
8:45AM UO 1400 IVF: PLR 1L x 12
CVP (opening pressure 8 cm H20)
(-) vomiting Volume per volume replacement of NGT output
(+) NGT Bilious output (300cc) q4 with PLR
Referred to Radio – to Fast Track WA CT
Abdomen: flat, soft, non scheduling
distended, non tender

01/29/2021 Give Omeprazole 80mg IV now then Omeprazole

4:30PM Drip 80mg in 90cc PNSS TRF 10 RTC
IM GASTRO
(+) coffee ground material per
NGT
 CHEST AP
01/28/2020

CHEST AP

Further progression of the previously noted opacities on

both lung parenchyma ascribed to Pneumonia

The heart is magnified.

Aorta is sclerotic
Mortality – Non Operative HD 10
Assessment Diagnostics VS Therapeutics
BP 100-120/60-70
01/30/2021 (HD10) ABG For Intubation – Verbal refusal by patient
HR 91-123
6AM CXR No available watcher
RR 21-28
CBC Na, K, 02 inhalation 9-10 lpm via FM
(+) labored breathing Cl, Mg T 36-36.6
Abdomen: soft, non-distended BUN, CREA SPO2 95-98%
(+) tenderness, LUQ CVP 8-9
CBC ELEC I 3440
HGB 100 Na 150 UO 2800
01/30/2021 NGT 1400 billous
CPR started
7:15 HCT 0.33 K 3.6 Epinephrine 1 amp IV q2-3 mins
(+) DOB / Desaturations WBC 34 Cl 114 Intubation done
BP = 0 / HR = 0 N 88.5 BUN 20 Noradrenaline drip
12l ECG -ASYSTOLE L 5.6 CREA 147 Hook to Mech Vent
Revived at 4th epi PLT 496 CBG 48 Salbutamol + ipatropium neb now
HR 100s BP: 70 palpatory 12 L ECG - AF D5050 1 vial now

8:30 AM ABG
Maintain MV settings for now
IM PULMO pH 7.27
For repeat Chest Xray
No need to transfer to ISO ward
PO2 105
01/30/2021 (HD10) 12L ECG – ASYSTOLE PCO2 52.9 Clinically pronounced dead at 11:40PM
11:20 PM HCO3 25
BP = 0 HR = 0 CO2 52
Fixed dilated pupils S02 97.2
 CHEST AP
01/30/2020

CHEST AP

Pulmonary Edema with possible concomitant infectious

process

Both costophrenic sulci are blunted denoting pleural

effusion

The heart is magnified.

Aorta is sclerotic