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Mortality Conference

Mortality Conference. M/68 Date of Admission : 2009.07.07 Date of Death : 2009.07.22 2009.08.06 발표자 : R1 이소령 . Chief complaint. Cough (onset:4 MA). Present Illness.

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Mortality Conference

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  1. Mortality Conference M/68 Date of Admission : 2009.07.07 Date of Death : 2009.07.22 2009.08.06 발표자: R1 이소령

  2. Chief complaint Cough(onset:4 MA)

  3. Present Illness 45PY의 Ex-smoker로 내원 4개월 전 시작된 cough, sputum, dyspnea onexertion으로 외부병원 방문, Chest X-ray 소견에서 폐렴 의심된다 듣고 치료 받았으나 호전 없었음. 이에 6월 말 외부병원에서 chest CT시행하였고 폐암 의심되는 소견으로 further evaluation위해 입원.

  4. Past Medical History • DM/HTN/Tbc/CLD (-/-/-/-) • HIVD로 타 병원에서 수술 받음 (10YA) • Trauma로 인한 어깨 손상으로 수술 받음 (5YA) Social History Smoking : 45PY (내원 2개월 전부터 금연) Alcohol : 소주 반 병, daily (약 50년간), 최근 금주함

  5. Systemic review General weakness(+), Fever/Chill (-/-), Wt loss (-) Cough/Sputum/Rhinorrhea (+/+/-) Sore throat(-) Dyspnea (-) Orthopnea (-) DOE (+) Chest pain/Palpitation (-/-) Abdominal pain (-)A/N/V/D/C (-/-/-/-/-), H/M/H (-/-/-) Urinary Symptom (-)

  6. Physical examination V/S>129/80-85-22-37.0 SpO2 92% G/A>not soIll-looking Alert, orientation: T/P/P(+/+/+) HEENT> Pupil 3mm/3mm isocoric, prompt Not anemic, anicteric PI/PTH (-/-) Not Dehydrated tongue No palpable LN

  7. Physical examination Chest> Symmetric expansion without retraction Crackle at RLLF RHB without murmur Abdomen> Soft flat. Normoactive bowel sound T/RT(-/-) L/S/K(-/-/-) Back and Extremity> CVAT (-/-), P/C/C (-/-/-)

  8. Initial Lab Findings CBC:9500-13.2-207K (seg 75.4%) E’:134-4.3-99-25 B/Cr 20/1.2 Ca/P 13.4/2.7 iCa 1.76 LFT:223-7.1/3.6-1.0-43-33/17 PT 65% hsCRP:0.94 LDH 555 CEA 782

  9. Chest X-ray

  10. Chest CT (o/s 09/6/26)

  11. PFT (09/7/9) • FEV1 3.65L (99%) • FVC 2.23L (88%) • FEV1/FVC 61% • DLCO : poor cooperation

  12. Initial Problem lists #1.Cough, sputum, DOE #2.Abnormality on Chest imaging …Consolidative mass, RLL …Emphysematous lung, bullae #3.Hypercalcemia #4.Performance status ECOG 2

  13. #1.R/O lung cancer …combined pneumonia #2.R/O underlying COPD #3.Hypercalcemia …d/t r/o paraneoplastic syndrome …d/t r/o bone metastasis Initial Assessment

  14. Initial Plans #1.Tissue confirm by PCNB, staging w/u #2.Consider antibiotics #3.Hydration, bisphosphonate, PTH check

  15. HD#1 -3 HD#1-3 S> cough, sputum, whitish/blood tinged.DOE O> Room air state, SpO2 94-98% RR 22-24 ABGA 7.458-33.4-66.0-24.7 (sat 92.3) PCNBx : non-small cell carcinoma / PTH <5 A> #1.Non-small cell lung cancer #2.Hypercalcemia P> FDG-PET시행 Pamidronate 투여

  16. CT guided PCNB

  17. HD#4 HD#4 S> F/C (+/+) C/S (+/+) dyspnea (+) BTS (+) O>V/S 111/73-115-24-38.8 (SpO2 88%) Room Air ABGA 7.487-26.4-67.8-22.7 (sat 93.2%) O2 5L공급하고 SpO2 96%이상 유지, RR 24 CBC 10790-12.4-145K (seg 90.4%) CRP 4.77 D-dimer 36.71

  18. O> FDG-PET : malignancy in consolidative mass in RLL with suggestive of LNs metastasis in rt. Hilar, mediastinal area with suggestive of liver & skeletal metastases A> #1. Non-small cell lung cancer, stage IV #2. r/o pneumonia #3. r/o pulmonary embolism P> #1. HMO transfer #2. antibiotics start #3. CT chest pulm. A + deep vein 시행 #4. consider LMWH HD#4

  19. CT chest pulmonary artery + Deep vein 3D

  20. HD#5-6 HD#5-6 S> F/C (+/-), cough (+) sputum (+) : whitish fever 있을 때 두통 동반된다 함. O> neck stiffness (-) O2 demand 5L → 2L, SpO2 98%, RR 22-24 CBC 6500-11.7-152K (seg 75.7%) CRP 5.71 Ca/P 9.3/2.3 P> antibiotics 유지

  21. O> B/Cx, Sputum Cx : no growth Pathology confirm> Favor Squamous cell carcinoma A> #1. pneumonia #2. lung cancer stage IV (SqCC, M/bone, liver, LNs) #3. intermittent headache …r/o brain metastasis P> #1. antibiotics (piperacillin/tazobactam + levofloxacin) #2. consider palliative chemotherapy #3. consider Brain imaging HD#7-8

  22. S> F/C (+/-), cough (+) sputum (+) BTS (+) O> V/S 105/65-90-24-37.5 (SpO2 93% on O2 4L) CBC 10160-12.0-234K (seg 66.8%) CRP 5.79 CXR : Decrease in extent of consolidation in RLL Brain MRI : no evidence of metastasis P> antibiotics 유지 HD#9-11 HD#9-11

  23. S> F/C (+/-), cough (+) sputum (+) BTS (+) O> V/S 112/69-98-22-37.7 (SpO2 93% on O2 4L) P> antibiotics 유지 palliative GP#1 start 94W transfer HD#12 HD#12

  24. S> F/C (-/-), cough (+) sputum (+) O> V/S 102/67-86-22-36.0 (SpO2 93% on O2 4L) ABGA 7.359-36.7-64.6-20.8 (sat 91.5%) CBC 16120-10.0-177K (seg 92.6%) CRP 1.47 CXR : RLL consolidation의 큰 변화 없음 P> antibiotics 유지 supportive care HD#13-14 HD#13-14

  25. S> F/C (-/-), cough (+) sputum (+) 컨디션 좋다. O> V/S 120/79-93-24-37.0 (SpO2 90% on O2 4L) O2 4L ABGA 7.394-33.5-58.5-21.2 (sat 88.5%) P> antibiotics 유지 (continued) HD#15 HD#15

  26. 오후부터 dyspnea 호소하면서 O2 demand 증가 21:00 O2 4L SpO2 78% → O2 6L SpO2 91% RR 20-24 23:00 O2 6L ABGA 7.440-24.6-44.5-19.1 (sat 78.6%) HD#16 01:00 V/S 105/74-109-30-35.7 O2 6LSpO2 83% → O2 7L 92% 10:00 O2 7L SpO2 77% RR 30, severe dyspnea호소 11:45 O2 10L, RR 28 → O2 12L 13:00 r/o pulmonary embolism 위해 D-dimer 및 Chest CT시행 D-dimer 5.12, CT소견 (continued) HD#15-16

  27. CT chest Pulmonary artery + deep vein 3D

  28. O> CBC 18400-10.7-26K (seg 92.5%) E’ 131-4.3-97-17 BUN/Cr 24/1.1 LFT 239-6.7/2.9-2.7-104-76/48 CRP 3.30 PT 48% aPTT 45.6 Fibrinogen 68 호흡기 내과 consult > Recommend -> O2, antibiotics (tazocin+levofloxacin iv) -> ventolin/atrovent nebulizer, aminophylline iv - if needed, elective intubation & MV support, ICU monitoring (continued) HD#16

  29. 15:00 O2 12L SpO2 77% RR 32→ O2 full 15:10 O2 full SpO2 check잘 안됨 RR 34 severe dyspnea 호소 15:20 Respiratory arrest 맥박 촉지 되지 않음 CPR start ABGA 6.943-38.2-48.0-7.4 (sat 50.4) 15:32 intubation 16:05 expire HD#16

  30. Cause of Death #1. Respiratory failure …d/t Pulmonary thromboembolism …d/t Pneumonia aggravation, underlying emphysematous lung #2. r/o Sepsis

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