mortality conference

1. Systemic
Lupus
Erythematosus
Morbidity and Mortality Conference

2.  E. R. B.
 16-year-old
 Female
 Filipino
 Iglesia Ni Kristo
 Born on December 30, 2006
 From San Pablo, Umingan,
Pangasinan
 Admitted on February 16, 2023
General Data

3. Abdominal pain
Chief Complaint

4. History of Present
Illness
 Known case of Systemic Lupus Erythematosus
diagnosed last June 2021 at R1MC with
unrecalled medications
 Initially presented with
 generalized erythematous lesions
 undocumented fever
 Discharged improved, was lost to follow-up,
non-compliant to medications

5. History of Present
Illness
 5 months PTA
 Dizziness
 No hair loss, joint pain, dysuria/hematuria,
chest pain, DOB
 Managed as Anemia at R1MC
 transfusion done
 sent home improved

6. History of Present
Illness
 2 months PTA
 Generalized abdominal pain, vague in
character
 Vomiting of previously food, ~1/2 cup
of bout
 Consult done at Manila
 given unrecalled medications with
noted improvement

7. History of Present
Illness
 4 days PTA
 Abdominal pain
 Vomiting
 Loss of appetite
 No fever, cough, colds, joint pains, dysuria,
chest pain, headache

8. History of Present
Illness
 Persistence of condition prompted
consultation in our institution and was
initially seen by Surgery department
 Admitted as a case of to consider
partial intestinal obstruction

9.  Previously admitted at R1MC
 2021 – diagnosed with SLE
 2022 – diagnosed with SLE and Anemia,
blood transfusion done
 No bronchial asthma, allergies to food and
medications
 No history of measles, mumps, rubella and
chicken pox
 No intake of medications
Past Medical History

10. ✗ Asthma
✗ Hypertension
✗ Systemic Lupus Erythematosus
✗ Diabetes mellitus
✗ Arthritis
✗ Cardiovascular diseases
Family History

11.  Father, 40-year-old, elementary graduate,
tricycle driver
 Mother, 38-year-old, elementary
graduate, house helper
 Only child of her parents
 Currently living with her grandmother
and grandfather on maternal side
Social and Environmental History

12.  No family member with the same illness
 Lives in non-congested bungalow house
with 1 room with 3 occupants
 Source of water from deep well
 Drinking water from water refilling
station
 They have no pets
Social and Environmental History

13. General Survey
✗ weight loss
✗ sweats
good oral intake
Integumentary
✗ pallor
✗ rashes
✗ itching
Head & Neck
✗ headache
✗ tearing
✗ ear discharge
✗ nose bleeding
✗ sore throat
Cardiovascular
✗ edema
✗ cyanosis
✗ murmur
Respiratory
✗ cough
✗ difficulty of breathing
✗ colds
✗ melena/hematochezia
Genito-urinary
✗ hematuria
✗ frequency
✗ dysuria
Musculoskeletal
✗ deformities
✗ trauma
✗ fractures
Endocrine
✗ polyphagia
✗ polidipsia
Nervous
✗ syncope
✗ seizures
Review of Systems

14. General Appearance: awake, irritable, in cardiorespiratory distress
Vital Signs: BP 120/80mmHg, CR 160bpm, RR 53cpm, T 39C, O2 98%
at FM 5lpm
Anthropometric measurements: 48kg (<0 ZS), 156cm (<0 ZS), BMI 19.7
Skin: ✓pallor, ✗jaundice, warm to touch, good skin turgor, ✗rashes
HEE: ✗lesions, non-sunken eyeballs, ✗periorbital edema, anicteric
sclera, pale palpebral conjunctiva, ✗discharge, dry lips, dry buccal
mucosa
Neck: ✗vein engorgement, ✗CLAD, ✗tenderness
Chest & Lungs: symmetrical expansion, ✗lagging, ✗subcostal
retractions, ✗crackles & wheezing
Heart: adynamic precordium, PMI at 5th ICS LMCL, tachycardic, regular
rhythm, ✗thrills, ✗murmur
Abdomen: Globular, distended, abdominal circumference 26.4cm, dull,
✓tenderness on LUQ on light palpation, ✗organomegaly
Genitalia: grossly female
Physical Examination

15. General Appearance: awake, irritable, in cardiorespiratory distress
Vital Signs: BP 120/80mmHg, CR 160bpm, RR 53cpm, T 39C, O2 98% at FM
5lpm
Anthropometric measurements: 48kg (<0 ZS), 156cm (<0 ZS), BMI 19.7
Skin: ✓pallor, ✗jaundice, warm to touch, good skin turgor, ✗rashes
HEE: ✗lesions, non-sunken eyeballs, ✗periorbital edema, anicteric sclera, pale
palpebral conjunctiva, ✗discharge, dry lips, dry buccal mucosa
Neck: ✗vein engorgement, ✗CLAD, ✗tenderness
Chest & Lungs: symmetrical expansion, ✗lagging, ✗subcostal retractions,
✗crackles & wheezing
Heart: adynamic precordium, PMI at 5th ICS LMCL, tachycardic, regular rhythm,
✗thrills, ✗murmur
Abdomen: Globular, distended, abdominal circumference 26.4cm, dull,
✓tenderness on LUQ on light palpation, ✗organomegaly
Genitalia: grossly female
Extremities: no gross deformities, full & equal peripheral pulses, <2s CRT
Physical Examination
General Appearance: awake, irritable, in cardiorespiratory distress
Vital Signs: BP 120/80mmHg, CR 160bpm, RR 53cpm, T 39C, O2 98% at FM
5lpm
Skin: ✓pallor, ✗jaundice, warm to touch, good skin turgor, ✗rashes
HEE: ✗lesions, non-sunken eyeballs, ✗periorbital edema, anicteric sclera,
pale palpebral conjunctiva, ✗discharge, dry lips, dry buccal mucosa
Heart: adynamic precordium, PMI at 5th ICS LMCL, tachycardic, regular
rhythm, ✗thrills, ✗murmur
Abdomen: Globular, distended, abdominal circumference 26.4cm, dull,
✓tenderness on LUQ on light palpation, ✗organomegaly

16. Awake, irritable
Cerebellum: no nystagmus
Cranial Nerves
CN I: not assessed
CN II: 2 mm ERTL, bilateral
CN III, IV, VI: intact extraocular muscles
CN V: positive corneal reflex
CN VII: no facial asymmetry
CN VIII: intact hearing
CN IX, X: intact gag reflex
CN XI: turns head from side to side
CN XII: tongue at midline
Sensory: 100% on all extremities
Motor: 5/5 in all extremities with good tone and bulk
DTR: ++ in all extremities
Meningeal: no neck rigidity
Neurological Examination

17. Admitting Diagnosis
T/C Partial Intestinal
Obstruction;
Systemic Lupus
Erythematosus in flare

18. Admission (Surgery)
S/O A P
(+) abdominal pain
(+) vomiting
(-) fever
110/70
140
22
36.6
99%
(+) generalized pallor
(+) abdominal tenderness all
quadrants
T/C Partial
Intestinal
Obstruction
Cannot totally
rule out gyne
pathology
IVF: PLRS 1L x 8
NPO, FM 5LPM
Dx: CBC, Ab RH, PT, INR, UA w/ PT, FA,
BUN, Na, K, Crea, CXR PA, FPA, RAT, RT-
PCR
Tx:
 Cefoxitin 62.5mkD q8
 Paracetamol 12.5mkd q6 PRN pain
 Omeprazole 1mkd OD
 4 ’u’ 250 cc pRBC
Seen by Gyne:
For TVS
Course in the Ward

19. Admission (Surgery)
S/O A P
(+) abdominal pain
(+) nausea
(+) vomiting
(-) fever
130/80
133
20
36
99%
(+) generalized pallor
(+) abdominal tenderness all
quadrants
T/C Partial
Intestinal
Obstruction
SLE in flare, Lupus
enteritis
Cannot totally
rule out gyne
pathology
Seen by Gen Pedia:
Start Hydrocortisone 2mkd q6
Start Metronidazole 31.25mkD q8
Repeat crossmatching after 24h
For Coomb’s test, PBS, reticct, C3, ANA,
UPCR
↑ O2 FM 10LPM
To ICU
Refer to Nephro and Rheuma
Course in the Ward

20. 1st Hospital Day (Surgery)
S/O A P
(+) diffuse abdominal pain
(+) bowel movement
(-) vomiting
(-) fever
130/80
140
30
36.5
99%
(+) generalized pallor
(+) generalized abdominal
tenderness LUQ>LLQ, RLQ,
RUQ
T/C Partial
Intestinal
Obstruction
SLE in flare, Lupus
enteritis
IVF: PLRS 1L x 8
NPO, FM 10LPM
Dx: repeat FPA, WAB CT triple contrast
Tx:
 Cefoxitin 62.5mkD q8 Day-1
 Metronidazole 31.25mkD q8 Day-1
 Paracetamol 12.5mkd q6 PRN pain
 Omeprazole 1mkd OD
 Still for BT
Seen by Nephro:
For KUB-UTZ, ANA, anti-DSDNA, C3
Course in the Ward

21. 2nd Hospital Day (Surgery)
S/O A P
(+) abdominal pain
(-) nausea/vomiting
(+) bowel movement
(-) fever
120/70
140
20
36.4
100%
(+) generalized pallor
(+) generalized abdominal
tenderness
SLE in flare, Lupus
enteritis
IVF: PLRS 1L x 8
Soft diet, FM 10LPM
Dx: crossmatching
Tx:
 Cefoxitin 62.5mkD q8 Day-2
 Metronidazole 31.25mkD q8 Day-2
 Paracetamol 12.5mkd q6 PRN pain
 Omeprazole 1mkd OD
 Still for BT
For TOS to Rheuma
Course in the Ward

22. 2nd Hospital Day (Pedia)
S/O A P
120/70
170
35
36.4
100%
↓
Lethargic
146
46
92%
Sepsis;
SLE in flare, Lupus
enteritis
PNSS 20 cc/kg x 1hr
Facilitate BT once compatible
↓
Stand-by intubation
Condition explained to watcher
For stat ABG
Course in the Ward

23. 2nd Hospital Day (Pedia)
S/O A P
↓
Lethargic
170’s
50’s
97% FM 10LPM
Sepsis;
SLE in flare, Lupus
enteritis
↓
‘E’ intubation ET 6.5 LL 18
AC 60-30-270 (6)-5
Shift Cefoxitin to Ceftriaxone 2g (max)
q12
For Blood CS, CBC, Na, K, AST, ALT, BUN,
Crea, PT INR, APTT, TB, B1, B2
For ABG, CXR APL
IVF to D5NM 60 cc/kg/day (MR+30%)
NPO
Course in the Ward

24. 2nd Hospital Day (Pedia)
S/O A P
Sepsis;
SLE in flare, Lupus
enteritis
For Methylprednisone pulsing if okay
with IDS
↓
Okay with Nephro and IDS to start
Methylprednisone pulsing
Course in the Ward

25. 3rd Hospital Day (Pedia)
S/O A P
BP unappreciable
Bradycardia at 50’s
O2 saturation undetectable
↓
ROSC
100/50
150’s
30
100%
Sepsis;
SLE in flare, Lupus
enteritis
Start CPR and ambubagging
Give Epinephrine 1mg q3 mins
PNSS 20 cc/kg bolus
Start NE drip 0.3 ug/kg/m
↓
Total 5 doses Epinephrine given
MV to AC 100-30-310 (7)-4
Still for BT
Still for MPP
Course in the Ward

26. 3rd Hospital Day (Pedia)
S/O A P
↓
80/40
150’s
30
92-94%
Generalized pallor
Fixed dilated pupils
↓
HR 40’s
Desaturation at 40%
Sepsis;
SLE in flare, Lupus
enteritis
↓
Start Epinephrine drip 0.2 ug/kg/m
↑ NE drip to 0.5 ug/kg/m
↓
Start CPR and ambubagging
Start Epinephrine 1mg q3 mins x 1 dose
Watcher opted for DNR
Course in the Ward

27. Laboratory Findings
CBC 02/16 02/18
Hgb ↓69 ↓21
Hct ↓20 ↓7
WBC ↑11.78 ↑56.28
Neu 59.28 ↑76.95
Lym ↓21.8 ↓9.13
Plt 388 446
PT - ↑19.2 (1.3x)
INR - 1.61
APTT - 44.2
Blood type O+
Anemia with
Leukocytosis

28. Laboratory Findings
02/16 02/18
BUN 9.97 ↑13.62
Crea 0.6 ↑1.65
Na ↓134.1 ↑152.5
K ↓3.27 3.96
AST - 21.55
ALT - 11.45
TP - ↓61.11
Albumin - ↓22
Globulin - ↑39.11

29. Laboratory Findings
02/17 02/18
ESR - 3
CRP - ↑21.8
UPCR ↑3.77 -
Direct C 4+ -
Indirect C 2+ -
Retic ct ↑2.2 -

30. Laboratory Findings
UA 02/16
Color Orange
Transparency Sl. turbid
Protein +3
Glucose Negative
pH 5
SG 1.030
Ketone Trace
WBC 0-2
RBC 2-5
PT Negative

31. Laboratory Findings
ABG 02/18 02/19
pH 7.117 6.966
pCO2 17 16.5
pO2 194 232
BE -24 -28
HCO3 5.5 3.8
sO2 99 99

32. FLATE PLATE ABDOMEN 2/17

33. FLATE PLATE ABDOMEN 2/16

34. CHEST XRAY PA 2/16

35. Final Diagnosis
Septic Shock;
Enterocolitis secondary to
Mesenteric Vasculitis;
Systemic Lupus Erythematosus in
Activity: 1) Autoimmune Hemolytic
Anemia, 2) Nephritis, 3) Cutaneous,
4) Cerebritis