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case presentation

This case presentation discusses a 60-year-old housewife, Mrs. Ro, with a history of osteoporosis and passive smoking, who was admitted for dyspnea and respiratory distress. Chest X-ray revealed bilateral lung infiltration, and her condition escalated to pneumonia-induced ARDS and septic shock. Despite initial treatments including hydration and supportive care, sputum culture showed Acinetobacter baumannii with multiple drug resistance. The management plan included antibiotic therapy and steroid supplementation, resulting in stabilization of her blood pressure and overall condition.

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case presentation

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Presentation Transcript

  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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