1. Perpetual Succour Hospital
Department of Family & Community Medicine
MORBIDITY & MORTALITY
CONFERENCE
FEBRUARY 2010
Presentors: Liza D. Mariposque, M.D.
Philip March Alquizar, M.D.
Marie Micheau Conference Room
February, 2011

2. TOTAL HOSPITAL ADMISSIONS 1,213
 Internal Medicine 577 (47.57%)
 Pediatrics 215 (17.72%)
 Family Medicine 148 (12.20%)
 Obstetrics and Gynecology 138 (11.38%)
 Surgery 135 (11.13%)

3. FAMILY MEDICINE
Admissions : 148
OPD:
PSH : 273
Community : 14
House Case : 9
Co-managed : 44
Charity : 2
Mortality : 2

4. Family Medicine Cases
 AdultMedicine 78 (68.42%)
 Pediatrics 24 (21.05%)
 Surgery 9 (7.90%)
 OB & GYN 3 (2.63%)

5. FAMED LEADING CAUSES OF
MORBIDITIES
ADULT:
 Community Acquired Pneumonia
 Urinary Tract Infection
 Acute Gastroenteritis

7. ADULT MEDICINE 78(68.42%)
 HEENT 9
Upper Respiratory Tract Infection 1
Sinusitis 4
Maxillary, Bilateral
w/ Acute Bronchitis ………..….1
w/ DM 2 ……………1
Acute Tonsillitis 4
w/ Dyslipidemia ……………1
w/ HPN ……………1

8.  CARDIOVASCULAR SYSTEM 12
Hypertensive Urgency 4
©
w/ CAP-MR; …………………………1
Lichen Simplex Chronicus (toes);
Cholelithiasis; Uterine Myoma;
Chronic Venous Insufficiency; HCVD
w/ Dyslipidemia, UTI …………………..1

9. Hypertension Stage II 3
w/ Error of Refraction ……………1
w/ Hypertensive Nephrosclerosis,
w/ Maxillary Sinusitis ..……1
w/ DM2 ………………………….1
Dilated Cardiomyopathy 1
2ndary to HCVD, DM2,
w/ Viral Epidemic Keratoconjunctivitis

10. Chronic Stable Angina 1
w/ CAD, DM2, Colonic Polyp ………1
S/P Colonoscopy 2/11
Congestive Heart Failure 2
FC-II,HCVD, DM2 …………………1
FC-III, CD-AF w/ MVR; CAP-MR,
HCVD,CAD, DM2, DVI…………..1

11. Ŧ
Probable Aortic Dissection, 1
Proximal Aorta, HCVD, DM 2

12. INTERNAL MEDICINE
 RESPIRATORY SYSTEM 12
Acute Bronchitis 2
Pulmonary Tuberculosis 1
Class III w/ DM Type 2
Chronic Obstructive Pulmonary Disease 1
in Acute Exacerbation
w/ Ulcer-like-Dyspepsia

13. Community Acquired Pneumonia 8
Low Risk 2
w/ Asthmatic Component ……1

14. CAP - Moderate Risk 6
w/ DM 2, Uncontrolled ……………….….1
w/ HCVD, DM2, Dyslipidemia ……………….1
w/ CKD 2ndary to HPN Nephrosclerosis,
HCVD …………………………………..….1
w/ Maxillary & Ethmoidal Sinusitis ………1
w/ Lumbosacral Radiculopathy probably
2ndary to TB/Malignancy; Internal
Hemorrhoids; Cholelithiasis ……………..1

15. INTERNAL MEDICINE
GASTROINTESTINAL SYSTEM 5
Cholelithiasis 1
Chronic Liver Disease 1
2ndary to Schistosomiasis,
w/ Hypersplenism 2ndary to
Schistosomiasis …………………1
Decompensated Liver Cirrhosis© 1
2ndary to Chronic Hepatitis B Infection

16. Upper GI Bleeding 1
2ndary to Erosive Gastritis
w/ CKD 2ndary to
HPN Nephrosclerosis; HCVD;
CD-AF w/ MVR …………………….1

17. Adenocarcinoma, Rectosigmoid© 1
Anemia 2ndary to # 1
S/P Colonoscopy 2/21

18. INTERNAL MEDICINE
 GENITO-URINARY SYSTEM 10
Urinary Tract Infection 7
w/ Non-Ulcer Dyspepsia ……..1
w/ Rhinosinusitis …………………...1
w/ Essenntial HPN …………………...1
w/ HPN & Dyslipidemia …………….1
Acute Pyelonephritis 1
Ureterolithiasis, L 2

19. MUSCULOSKELETAL SYSTEM 1
MUSCULOSKELETAL SPASM 1

20.  SKIN 1
Cellulitis, R foot 1
w/ UTI

21. RHEUMATOLOGY 2
Acute Gouty Arthritis 2
S/P Arthrocentesis ………………………1
CKD 2ndary to Urate Nephrolithiasis,
w/ Indirect Hernia, L ………………..1

22. ONCOLOGY 2
Breast Carcinoma 1
Stage II-B, S/P Chemotherapy 8th Cycle
S/P Lumpectomy, R
Bronchogenic Carcinoma 1
w/ DM 2

23. INTERNAL MEDICINE
 NERVOUS SYSTEM 5
Benign Paroxysmal Positional Vertigo 2
w/ Non-Ulcer like Dyspepsia,
Nephrolithiasis© …………………….1
w/ Acute Gastritis …………………….1
Seizure Disorder 1
w/ Maxillary Sinusitis, HPN

24.  CARDIOVARCULAR DISEASE 2
Multiple Infarct, L MCA
w/ Seizure Disorder 2ndary to #1
HCVD, Hypercholesterolemia…….1
Pontine Infarct w/ HCVD, CAD…………..1

25. INTERNAL MEDICINE
 ENDOCRINE SYSTEM 1
Hypoglycemia 1
2ndary to Poor Food Intake, DM 2
w/ CAP- Moderate Risk

26. INTERNAL MEDICINE
INFECTIOUS 18
Systemic Viral Infection 2
Dengue Fever 4
Stage II
Typhoid Fever 2
w/ HPN …………………1

27. Acute Gastroenteritis 5
w/ some Dehydration 4
w/ Maxillary Sinusitis …………..1
w/ Moderate Dehydration 1
Intestinal Amoebiasis 2
w/ Mixed Hemorrhoids ……………1

28. Hepatitis A Infection 1
w/ Cholelithiasis
Ŧ
Septic Shock Syndrome 1
2ndary to CAP - High Risk
w/ Concomittant Non-ST Elevation
Myocardial Infarction

29. Human Immunodeficiency Virus Positive 1
w/ Multiple Intracranial Enhancing Lesion
(Toxoplasmosis),
UGIB probably 2ndary to Stress Ulcers
Gastropathy – Resolved.
w/ Herpes Zoster, R Thigh - Resolved

31. Mortality # 1
 T.D, 78 y.o., female, widow
 Mabolo, Cebu City
 CC: dyspnea, upper back pain
 Past Medical History: HPN, DM2
 Numbers of Hospital Stays: 5 days

32. Final Diagnosis
 PROBABLE AORTIC DISSECTION,
PROXIMAL AORTA
 HYPERTENSIVE CARDIOVASCULAR
DISEASE
 DIABETES MELLITUS 2

33. Mortality # 2
 N.C.,50 y.o., male
 CC: epigastric pain, dyspnea
 Past medical History: HPN
 Numbers of Hospital Stay: 4 Hours

34. Final Diagnosis
 Septic Schock Syndrome 2ndary to CAP High
Risk with Concomittant Non-ST Elevation
Myocardial Infarction

35. MORBID CASE
 V.V.,21y.o., male
 Medical Representative
 Talamban, Cebu City
 CC: fever, headache, changes in
behavior

36.  (-)HPN, (-) DM, (-) BA
 VICES: alcoholic beverage drinker,
smoker
 Allergy: shrimp
 HFD: BA

37. PAST MEDICAL HISTORY
2009 – AGE (PSH)
April 2010 – Pneumonia (PSH)
June – Nov. 2010 – PTB (CVGH)
Oct. 2010 – Optic Pneuritis & Glaucoma 2ndary to
adverse drug reaction to Ethambutol.

38. HPI
2 wks PTA – undocumented on & off fever.
No History of cough.
5 Days PTA – still with fever associated with
body malaise & headache.
Day PTA – changes of behavior.

39. BP: 130/90mmHg HR: 86bpm
RR: 20cpm T: 36.1C
Skin: no lesions, warm
HEENT: anecteric, dilated R pupil (5mm) & non-
reactive to light. (+) L eye reactive to Light
Neck:(-) LAD, no neck rigidity
C/L: ECE, CBS, (-)rales, (-)wheeze
CVS: DHS, NRRR, no murmur
Abd.: flat, NABS, nontender, no mass
GUT: (-)KPS
Ext. : No edema, strong pulses, no limitation in
movement

40. CNS: drowsy, incoherent, follows command
I – N/A
II, III, - dilated R pupil & non-reactive to light, L
pupil is reactive to light.
III, IV,VI – (+)EOM
V, VII – No facial asymmetry
IX, X, XI – (+) gag reflex, tongue at medline,
able to swallow & protrude tongue
XI – no shoulder lag

41. Sensory: Intact
Motor Strength: 5/5 all extremities
Reflexes: RU = +2 LU = +2
RL = +2 LL = +2
(-) Babinski sign
(-) Kernigs sign
(-) Brudzinsky sign

42. Admitting Impression:
 R/I
Bacterial Meningitis vs.
Space occupying Lesion

43. On Admission:
 Hypoallergenic Diet
 O2 inhalation at 2Lpm.
 IVF started @ 30gtt/min.
 Labs: CBC, U/A, Na, K, CXR, crea, CT-scan brain
plain
 Meds: Vit. B – complex 1 tab OD.
Mefenamic acid 500mg 1cap now.
Ceterizine 10mg 1tab OD
Ceftriaxone 2G IVTT q 12Hr.

44. Laboratory Results:
 CBC  U/A
WBC = 4.97 Glucose (-)
N = 63 Protein (-)
L = 20 pH 1.010
M=7 RBC = 0-2
E = 10
WBC = 0-2
Plt = 189
Epithelial = rare
Hb = 12.3
Mucus = rare
Hct = 35.7
Bacteria = rare

45.  CXR
No Significant
Findings  Na = 133
 K = 3.77
 Crea = 0.96

46. CT-SCAN BRAIN PLAIN
 Areas of ill-defined hypodensities with mass
effect in the R basal ganglia, R frontal & R
temporal lobes, R thalamus & R midbrain.
 Consideration include:
1. Cerebritis
2. Vasogenic Edema
3. Infection from Vasculitis

47.  Course in the Ward: Day 1-3
 P: fever, headache, rashes
 O: BP: 120/80-140/90 HR: 80-110bpm
RR: 20-24cpm T: 37.5-39C
Skin: (+) maculopopular rash, warm
HEENT: anecteric, dilated R pupil (5mm) & non-
reactive to light. (+) L eye reactive to Light
Neck:(-) LAD, no neck rigidity
C/L: ECE, CBS, (-)rales, (-)wheeze
CVS: DHS, tachycardic, no murmur
Abd.: flat, NABS, nontender, no mass
Ext. : No edema, strong pulses, no limitation in
movement

48. A: CNS INFECTION, R/I HIV INFECTION
P:For MRI of the brain w/ contrast.
> Rpt CBC
 For HIV Test & VDRL.
 For co-mgt w/ Neurologist.
 Refer to Allergology for clearance.
 Co-mgt w/ Infectious Specialist.
 Keppra 500mg 1tab BID.
 Mannitol 100cc IV q 6H.
 Iterax 50mg 1tab OD.
 d/c Ceftriaxone.

49. MRI OF THE BRAIN w/ Contrast
 Mulltipleminimally enhancing cerebellar and
brain stem lesion w/ perilesional edema and
mass effect.
 Primary consideration is an infectious CNS
process such as Toxoplasmosis.

50. HIV Test VDRL Test
 Qualitative Result
– Negative
 HIV Ag/Ab
457.71 s/co  CBC
Remarks: Positive WBC = 3.72
N = 54
L = 26
M=8
E = 12
Plt = 165
Hb = 12.1
Hct = 32.5

51.  Day 4-5
 P: fever, no verbal output but patient response
upon calling his name, (+) rashes, unable to eat
 O: BP: 110/70-140/90 HR: 80-150bpm
RR: 20-25cpm T: 39-41C

52. Skin: (+) maculopopular rash, warm
HEENT: anecteric, dilated R pupil (5mm) & non-
reactive to light and half open.
Neck:(-) LAD, no neck rigidity
C/L: ECE, CBS, (-)rales, (-)wheeze
CVS: DHS, tachycardic, no murmur
Abd.: flat, NABS, soft, nontender, no mass
Ext. : No edema, strong pulses, no limitation in
movement

53. A: HIV Infection, R/I CNS Infection
(Toxoplasmosis vs. Lymphoma)
UGIB etiology to be determine
P: NPO & NGT inserted.
- for HbsAg and anti-HCV determination.
- Piperacillin-Tazobactam 4.5G IV then 2.5G IV q
6H.
- Nexium 40mg IVTT OD.
- Fansidar 25/500mg 4tabs now then 1tab q 8H
once coffee ground vomitus disappeared.
- all P.O meds shifted to IV.

54. HbsAg = 1 (NR)
Anti-HCV = 1 (NR)
2 blood culture: negative

55.  Day 6-8
 P: fever, no verbal output but response upon
calling his name, recurrence of coffee ground NGT
drainage, (+) vesicular rash
 O: BP: 110/70-130/90 HR: 85-140bpm
RR: 20-22cpm T: 38-40C

56. Skin: warm
HEENT: anecteric, dilated R pupil (5mm) & non-
reactive to light and half open.
Neck:(-) LAD, no neck rigidity
C/L: ECE, CBS, (-)rales, (-)wheeze
CVS: DHS, tachycardic, no murmur
Abd.: flat, NABS, soft, nontender, no mass
Ext. : No edema, (+) vesicular rash on the R thigh,
strong pulses, w/ limitation in movement
on the L side of the body.

57. A: HIV Infection, R/I CNS Infection
(Toxoplasmosis vs. Lymphoma)
UGIB etiology to be determine, Herpes Zoster R
Thigh
P: NGT feeding started.
- for CD4 count and Toxoplasma Serologic IgG &
IgM determination.
- hold fansidar.
- Zithromax 500mg IV drip OD.
- Dalacin 300mg 1tab/NGT q 6H  hold
- Valtrex 1G 1tab q 8H/NGT  hold

58.  Dexamethasone 50mg IVTT q 6H.
 Zovirax 500mg IV infusion.
 Kabiven 1.4Kcal to run q 24H.
 Ice bath done.
 Refer to Neurosurgeon for possible brain
biopsy.

59.  Day 9 - 12
 P: fever, no verbal output but response upon
calling his name, (+) vesicular rash, (+) Chyne-
Stokes respiration
 O: BP: 110/70-140/80 HR: 85-160bpm
RR: 20-23cpm T: 37.5-40.8C

60. Skin:warm
HEENT: anecteric, dilated R pupil (5mm) & non-
reactive to light and half open.
Neck:(-) LAD, no neck rigidity
C/L: ECE, CBS, (+)rales both Lung field, (-)wheeze
CVS: DHS, tachycardic, no murmur
Abd.: flat, NABS, soft, nontender, no mass
Ext. : No edema, (+) vesicular rash on the R thigh,
strong pulses, w/ posturing/extension of L
upper extremities.

61. A: HIV Infection, R/I CNS Infection
(Toxoplasmosis vs. Lymphoma)
UGIB probably 2ndary to Stress Ulcer, Herpes
Zoster R Thigh
P: - Rpt CXR done.
- Resume Valtrex.
- Paracetamol given RTC.
- Mucosta 100mg 1tab BID.
- Hold Pepiracillin.
- Cefipime 2G IVTT q 12H.
-

62.  Acetylcytine 600mg mix in water BID.
 Salbutamol nebulization q 6H.
 Inc. Keppra 100mg 1tab BID.
 Inc. Mannitol 100cc q 6H.
 Family appraised for brain biopsy.

63.  Day 13 - 21
 P: fever, no verbal output but response upon
calling his name
 O: BP: 100/70-140/80 HR: 90-143bpm
RR: 19-23cpm T: 37.4-39.8C

64. Skin:warm
HEENT: anecteric, dilated R pupil (5mm) & non-
reactive to light and half open.
Neck:(-) LAD, no neck rigidity
C/L: ECE, CBS, (+)rales both Lung field, (-)wheeze
CVS: DHS, tachycardic, no murmur
Abd.: flat, NABS, soft, nontender, no mass
Ext. : No edema, strong pulses, w/ limitation in
movement on the L side of the body.

65. A: HIV Infection, R/I CNS Infection
(Toxoplasmosis vs. Lymphoma)
UGIB probably 2ndary to Stress Ulcer, Herpes
Zoster R Thigh
P: - continue all meds.
- family opted to transfer to other hospital for further
mgt.

66.  CD4 = 13.23  Markedly decrease T.
(N.V 535-1451) Lymphocytes.
 CD8 = 68.82  Markedly decrease
(n.v. 139-783) Helper T cells.
 CD4/CD8 = 0.2
 Normal T-suppressant
population.
(N.V. 1.5:1-2.7:1)

67. HIV Confirmatory Test Toxoplasma Serologic Test
 CLEIA: Reactive IgG Ab to Toxoplasma Gondii
Ag/Ab = 270.08 366.6 IU/mL
– Reactive
(N.V. >3.500)
 IgG Ab to Toxoplasma
Gondii
= 0.49 IU/mL (n.v ≤0.600)
negative

68. FINAL DIAGNOSIS
Human Immunodeficiency Virus Positive 1
w/ Multiple Intracranial Enhancing Lesion
(Toxoplasmosis),
UGIB probably 2ndary to Stress Ulcers
Gastropathy – Resolved.
w/ Herpes Zoster, R Thigh - Resolved