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case presentation

case presentation. By R3 張恩庭. Patient data. V20069127x A 60 year-old housewife Usual activity before admission: could walk by herself, but could not walk over than 1 km due to osteoporosis, with total hip replacement. Chief complain.

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case presentation

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  1. case presentation By R3 張恩庭

  2. Patient data • V20069127x • A 60 year-old housewife • Usual activity before admission: could walk by herself, but could not walk over than 1 km due to osteoporosis, with total hip replacement

  3. Chief complain • Mrs Ro is a 60 year-old housewife. She had second passive smoking about 1 pack per day for more than 30 years. She had past history of osteoporosis and post total hip replacement. She had taken pain-relief drugs occasionally. • She sufferred from dyspnea for three days. It accompanied with yellowish mucoid sputum. She went to LMD for help but in vain. Blood-coated sputum was noted 1 day before admission. Bilateral basal chest pain was noted while coughing. There was no fever or body weight loss. • She was brought to 玉里 hospital for first aid. Chest X ray showed bilateral infiltration over basal lungs. O2 could not easily kept under non-rebreathing mask used. She was transferred to our ICU for further care.

  4. Social history • Smoking: had passive smoking about 1 pack per day for 30 years • Alcoholic drinking: denied • Betel nuts chewing: denied

  5. Physical examination • --General appearance: acute ill-looking; dyspnea. • --Conciousness: alert. • --Mentality: clear • --Glasgow scale: E4M6V5 • --Vital signs: BT: 36.9degree Celcius. • HR: 96/min, RR:30/min. BP: 94/53 mmHg • SaO2: 92-96% under NRM used

  6. Physical examination • --Skin: grossly intact. no scaling. • --Lymphadenopathy: Neck (-). • --Head: normal. • --Eyes: conjunctiva: not pale, sclera: not icteric.pupils: isocoric; pupil size: (left/Right)3/3mm Light reflex: (+/+) • --Thyroid: not palpable. • --Jugular vein engorgement: 1 cm above Louis` angle. • --Chest wall: symmetric expansion, no tenderness.

  7. Physical examination • --Lung: Breathing sound: rales over bilateral lung basal area, decreasing breathing sound and percussion dulls on bilateral lower lung area • --Heart auscultation: Regular heart beat. • --Abdomen: mild obese, Globular. No muscle guarding or tenderness • --Kidney: not palpable, tenderness negative. • --Extremities:no pitting edema.

  8. Chest X ray while admission

  9. Admission impression • Pneumonia induced ARDS • Shock, septic

  10. Admission management • Hydration for septic shock • Supportive care for ARDS

  11. Laboratory data- ABG

  12. Laboratory data- CBC

  13. Laboratory data- BCS

  14. Laboratory data- BCS

  15. Laboratory data- pleural effusion

  16. Laboratory data • CRP: 16 while admission • ACTH/ Cortisol: 151/ 11.1 • Sputum culture: no growth on admission • Sputum culture: Acinetobacter Baumanii with multiple drug resistance (1 week after admission) • No blood culture grew • Bronchoscope brushing cytology: reactive methothelial cells and inflammatory cells • Bronchoscope brushing culture: Acinetobacter Baumanii with poly-drugs resistance

  17. Impression • pneumonia, PDR AB ? • Adrenal insufficiency

  18. Admission management • 1. hydration • 2. antibiotics of Penicillin and Cravit (D1) • 3. Steroid supplement: Solu-cortef 50mg q8hr (D3), after solucortef supply, systolic blood pressure returned to over 100mmHg, without dopamin and levophed used.

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