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CCU Conference
April 4, 2017
12:00NN -2:00 PM
MBFI Hall
Manila Doctors Hospital
Reporter:
Olivia Faye J. Listanco
3rd Year Medical Resident
Reactors:
Dr. Dante Morales Dr. Virgilio Banez
Dr. Elaine Alajar Dr. Luminardo Ramos
Dr. Elmer Llanes Dr. Gino Quizon
Dr. Ian Estanislao Dr. Des Roman
Dr. Albert Albay Dr. Ronald Santos
Dr. Noel Viado Dr. Arlene Afaga
Moderator:
Dr. Marjorie Obrado
CASE PROTOCOL
General Data: This is a case of DD, a 47-year- old female, married, Catholic, unemployed from Tondo, Manila.
Chief Complaint: Shortness of breath
Review of Systems:
General: (-) fever (-) weight loss
HEENT: (-) retro orbital pain, (-) diplopia
Respiratory: (-) intermittent cough, (-) hemoptysis, (-) dyspnea
Cardiac: (-) chest pain (+) lightheadedness/ dizziness (-) bipedal edema
GI: (-) diarrhea, (-) constipation, (-) hematochezia, (-) melena
Genitourinary: (-) dysuria, (-) hematuria, (-) discharge, (-) decrease in UO
Neuro: (-) seizure, (-) dizziness, (+) loss of consciousness
(11/23/16)
On second hospital day, patient was less dyspneic and no bleeding episode was reported however she had
complaints of epigastric pain. She had stable vital signs. Vascular cardiology inputs included a consideration of acute high
grade pulmonary embolism secondary to immobilization/ surgery; rule out hypercoagulable state; acute stress gastritis.
Serial partial prothrombin time tests were done and the Rashke protocol was used for the titration the maintenance dose
of the heparin. The target PTT ratio was 1.5-2.0. Initial CT angiogram was contemplated for the patient but due to
unavailability of the imaging study at that time, pulmonary angiogram was instead contemplated. Omeprazole was also
increase to 40mg/tab BID. Bilateral venous Doppler study of the extremities was also requested.
(11/24/16)
On the third hospital day, patient had minimal complaints of SOB and with stable vital signs. Heparin drip was on
hold and patient underwent pulmonary angiogram with possible catheter directed thrombolysis. Tolerated the procedure
and imaging study done showed left pulmonary artery (superior segment) and right pulmonary artery (superior segment)
lling defect and rest of the branches showed no signicant lling defects. Findings strongly indicated right and left
pulmonary arterial embolism and elevated main pulmonary arterial pressure. Patient then was transferred to the CCU for
systemic thrombolysis.
At the CCU, patient had had stable vital signs but still dyspneic. Systemic thrombolysis was started with
streptokinase 250 000 units IV bolus for 30 minutes, the maintained on 100 000 units/hour for 24 hours. Hydrocortisone
100mg IV was also given as pre-medications. Patient had low grade fever during infusion. No reported bleeding episodes,
or abdominal pains was made.
(11/25/16)
On the fourth hospital day, patient had improved dyspnea and rest of vital signs was normal. Patient still had in
going streptokinase drip. Patient had minimal bleeding at the venipuncture site which resolved with pressure dressing.
(11/26/16)
On the fifth hospital day, patient had no complaints of dyspnea, fever, or bleeding but had persistent non-
productive coughing. Vital signs were stable. On physical exam she developed crackles on the right mid to base lung.
Repeat laboratory tests were done. CBC showed increased levels of leukocytosis (WBC 13.63 16.68) and neutrophilic
predominance (Neutrophils 73 85). Chest x-ray done however showed no active infiltrates. Repeat urinalysis showed no
improvement in the degree of pyuria and bacteria as well. Hospital acquired pneumonia and complicated UTI were
entertained. and she was referred to infectious disease service. Sputum culture was done and Clindamycin was initially
shifted to Levofloxacin 500mg tab OD then to Piperacillin tazobactam 4.5gm IV Q8.
PTT ratio was 1.11 and Enoxaparin 0.6cc SQ Q12 was started. She was also the transferred to the female
medicine ward.
(11/27/16)
On the sixth hospital day, patient still had coughing episodes but no recurrence of fever. Tachycardia was also
noted at 90-110s and she was started on Lanoxin 0.25mg/tab OD. Piperacillin tazobactam for the HAP and for the PE
Enoxaparin were continued and overlap of Warfarin 2.5mg/tab 1 tab ODHS was started too.
(11/28-29/16)
On the seventh and eighth hospital day, patient had stable vital signs. Antibiotics and anticoagulants were
continued. Histopathologic report for the TABHSO done showed no indication of an active malignancy. Patient was able to
tolerate a 6minute walk with no complaints of difficulty of breathing.
(11/30/16-12/1/16)
On the ninth hospital day, patient had no subjective complaints and vital signs were normal. Repeat CBC showed
improved leukocytosis and for the HAP and UTI, Piperacillin tazobactam was shifted to Levofloxacin 750mg/tab OD.
PT/INR was 1.22 (Target= 2-3), hence discharged was deferred and warfarin was increased to 2.5mg 1 tab ODHS and
enoxaparin was continued. Ambulation was encouraged and continued.
Tenth hospital day was uneventful.
(12/2-3/16)
On the eleventh hospital day, patient had no subjective complaints and vital signs were normal. Repeat CBC
showed further improvement on the resolution of infection. PT/INR was 1.52 and warfarin was increased to 5mg/tab
ODHS and enoxaparin to 0.8cc SQ ODHS (1.5mg/kg/day).
Twelfth hospital day was uneventful.
(12/4/16)
On the thirteenth hospital day, patient had stable vital signs. Repeat PT/INR was 2.1, and enoxaparin was
discontinued. Patient was discharged with following medications, Warfarin 5mg, 1 tab OD, Lanoxin 0.25mg OD, and
Levofloxacin 750mg OD to be completed for 7 days (11/5/16).
Nothing follows