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Bioethics Case

ANDAL, ANDALES, ANG. Bioethics Case. HISTORY. GENERAL DATA MA, 43/F, married, Roman Catholic, R-handed from Quezon City CHIEF COMPLAINT Dyspnea. CLINICAL HISTORY. PATIENT PROFILE

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Bioethics Case

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  1. ANDAL, ANDALES, ANG Bioethics Case

  2. HISTORY GENERAL DATA MA, 43/F, married, Roman Catholic, R-handed from Quezon City CHIEF COMPLAINT Dyspnea

  3. CLINICAL HISTORY PATIENT PROFILE A diagnosed case of Breast CA, Stage 3B (Apr 2008); undergone 4 cycles of chemotherapy (latest session Mar 2009 PGH-CI) Nondiabetic and non-asthmatic

  4. HISTORY OF PRESENT ILLNESS 4 months PTA, pt’s chemotherapy session was deferred due to decreased CBC results and occurrence of left pleural effusion. Pt was lost to follow-up and noted to be experiencing dyspnea, necessitating nebulization with salbutamol at least 4x/day. 3 weeks PTA – pt had onset of cough with whitish phlegm, (+) easy fatigability, fever (relieved by paracetamol 500 mg/tab prn), 2-pillow orthopnea

  5. HISTORY OF PRESENT ILLNESS 2 weeks PTA, (+) worsening of dyspnea, New Era Hospital, admitted, Dx: Malignant Pleural effusion; chest tube thoracotomy done (L); Meds: tramadol, co-amoxiclav, other unrecalled meds 3 days PTA, discharged; referred to PGH for 2D echo and continuation of radiation therapy; still with mild dyspnea Day of admission: worsening of symptoms, (+) generalized weakness, consulted at PGH, admitted

  6. REVIEW OF SYSTEMS • (-) fever, (-) vomiting (+) anorexia, (+) weight loss, (+) easy fatigability • (-) headache, dizziness, cough, colds, epistaxis, BOV, otalgia • (+) chest pain (-) palpitations • (-) abdominal pain, diarrhea, constipation, hematemesis/melena/hematochezia • (-) polyuria, polydipsia, polyphagia • (-) hematuria, frequency, dysuria, urgency • (-) cyanosis, jaundice, seizures, (+) pallor

  7. Past Medical History • (+) HPN (1997, uncontrolled) • (-) Goiter (2000) • (-) PTB, DM, BA • (-) allergies to foods and meds • (-) previous surgeries • Family Medical History • (+) HPN, BA – both parents • (-) Goiter, DM, allergies • (-) history of cancer in the family • Personal/ Social History • Patient is a college graduate, a graduate of midwifery, but worked as a saleslady until 1996. She is married with 2 children. His husband is an OFW and is the breadwinner of the family. The patient has no vices. She denies illicit drug use.

  8. PHYSICAL EXAMINATION

  9. COURSE AT THE ER • 1st HD 7/19/09 Patient hooked to O2 support at 10 lpm via face mask; A> Malignant pleural effusion, L, s/p CTT (July 2009) vs Obstructive Pneumonia, Breast CA t/c pulmo metastasis. • Labs: ABG done which showed respiratory alkalosis (compensated). CBC done showed elevated WBC and neutrophil counts (infection) • Meds: Piperazillin + Tazobactam 4.5 g IV q 8h , paracetamol 500 mg/tab q 4 for fever prn. • POD II: A> Breast Carcinoma Stage IV with Liver Metastasis (t/c Lung Metastasis) with Secondary Bacterial Infection, Malignant Effusion, R; s/p CTT with pleurodesis (July 2009), Hypertension, controlled. • Meds: Shift Pip-Tazo to 1) Oxacillin 2 g IV Q6 2) Clindamycin 300 mg/cap 1 cap Q6 PO. Maintained O2 at 4 lpm via NC. (Referred to TCVS for CTT, Hospice, Med Onco)

  10. 2nd HD 7/20/09 DAY MHAPOD: Pertinent PE: Pale conjunctivae, + chest lag, L,decrease breath sounds and fremiti, L, (-) crackles/wheeze. (+) breast mass, L with purulent discharge. • Labs: Chest UTZ with markings, PBS with reticulocyte count. • Meds: Discontinued clindamycin; Start levofloxacin 500 mg/tab OD; Start Moriamin Forte 1 cap BID; Appeton 500mg/tab at HS OD. Continue other meds; (Referred to GS1 for possible thoracentesis.) CDW BID of breast mass wound with Daikin’s Solution. • DAY MHAPOD: S> (+) pleuritic chest pain, lung findings unchanged. • Meds: Continue Oxacillin, hold clindamycin. To start Levofloxacin at 750 mg OD. Continue other meds. Transfusion 4 ‘u’ FFP now then 2 ‘u’ Q12; transfuse 1 ‘u’ pRBC; (Surgery referral done once with chest markings.)

  11. 3rd HD7/21/09 DAY MHAPOD: Patient noted to have decreased serum Mg • P> IVF: MgSO4 drip: 3 g MgSO4 + 250 D5W x 12 hrs; IL pNSS x 12 hrs. • 4thHD 7/22/09 NIGHT MHAPOD: Enalapril20 mg/tab OD started • 5th HD 7/23/09 NIGHT MHAPOD O> decreased breath sounds over L base, (+) decreased breath sounds over the R mid-base, (+) vocal fremiti B bases • Meds: Continue Oxacillin (D0 + 3), Levofloxacin (D2); Plan was to insert CTT c/o TCVS; Patient admitted at W1B19.

  12. Physical Examination PE on Ward Admission

  13. ASSESSMENT Breast Carcinoma Stage IV with Liver Metastasis (t/c Lung Metastasis) with Secondary Bacterial Infection Malignant Effusion, R s/p CTT with pleurodesis (July 2009) Hypertension, controlled

  14. COURSE IN THE WARDS • 6th HD 7/24/09 Patient is persistently tachypneic, BP 120/80, HR 120, RR 36, O2 sat remains 97-98%; refused to be intubated; signed with advanced DNI directive. • 7th HD 7/25/09 11PM Patient referred for decreased BP of 70/50, HR 50s, RR 12, O2 sat at 60%. Soon after, code was called, CPR was started with O2 support via facemask and ambubag. Patient’s husband arrived and decided to reversed previous DNI directive. Patient then intubated and ACLS was started. Patient was revived after 4 min of cardiopulmonary arrest. Patient was hooked to Dopamine and mechanical ventilator.

  15. 8th HD 726/09 Still hooked to Dopamine 2 ampules in 250 cc D5W at 48 cc/hr (20 mcg/kg/min) at max dose; BP was stable at 110-90/70-60, HR 140s, RR48; • Patient’s husband reluctant to pursue further laboratory exams; DNR was comtemplated but never consented. • 10 AM Patient’s BP went down to 70/40; Dobutamine drip was started as ampules in 250 cc D5W @ 36 cc/hr at max dose. BP maintained at 90-70/60-40. No further inotropes started.

  16. 9th HD 7/27/09 9 AM Patient referred for BP 60/40, HR 68, RR 36; Soon after, second code was called; ACLS was started. At 9 mins post arrest, pt’ s husband decided to stop further resuscitation attempt. Patient maintained on 02 support via facemask on continuous ambubagging; no CPR was pursued until cardiac monitor read as asystole. Patient was then declared dead.

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