Home » Uncategories » STUDI KASUS B

STUDI KASUS B

Edit


CASE II
PATIENT DATA BASE
A.  Patient Description:
  • Name         :    ZEH 
  •  Age           :  35 years
  • DOA         :    21/09//07 
  •  Gender       :  Female 
  •  Ward         :    ICU/B7                                   

B.   Chief complaint:
Cough, SOB, fever – 3/7

C.   History of present illness:
Miss. ZEH is a 35 year-old woman brought to ICU on 21st of Sept 2007 from BM hospital because complaining of cough, SOB and fever for past few days. She was admitted to BM hospital on the morning of 21st of Sept and was diagnosed as severe Community Acquired Pneumonia (CAP). She was then sent to Hospital Pulau Pinang on same day in the afternoon for intubation due to compensated metabolic acidosis. In Hospital Pulau Pinang, she was diagnosed as severe CAP and secondary sepsis.

D.   Past Medical History
  1. Hypertension
  2. DM


E.   Family/Social History
·         Not known family history of any medical illness.
·         Not married.
·         Non-smoker. Alcohol intake?

F.   Allergies
NKDA.

G.   Past Medication History
Could not be obtained.

H.   Review of System
·         O/E – alert, tachypneic, obese
·         BP – 110/70
·         P – 150
·         T – 37.5
·         SPO2 – 66 – 70%
·         CXR – Bilateral opacity
·         Lungs – fairly clear



I.   Laboratory Investigation
DATE
21/9
22/9
23/9
24/9
25/9
BLOOD
CHEMISTRY
NORMAL





Na+
135-145 mmol/L
131
137
145
149
141
K+
3.5-5.0 mmol/L
3.9
4.6
3.5
3.7
4.0
BUN
1.7-8.3 mmol/L
9.4
7.7
8.0
9.5
9.5
Creatinine
57-130 mmol/L
79
77
67
56
53
Cl
96-106 mmol/L
100
114
114
116
113
Cr Cl
75-125 ml/min
124
128
146
176
185
Mg+
0.8-1.0 mmol/L
0.7
1.22


Ca2+
2.1-2.55 mmol/L
1.82
1.79


PO4
0.89-1.40 mmol/L
1.24











HEMATOLOGY






Hct
36-46%
33.3
32.1
30.5
33.4
31.6
HgB
12-16g/dl
11.6
10.6
9.9
10.8
10.1
WBC
4.5-11 x109/L
11.7
11.0
10.4
11.4
10.6
RBC
4.7-6.1 x 1012/L

3.5
3.8
3.5
PLT
130-400 x103/mml
98
160
191
266
270
LYM
16-45%





NEUT
45-74%












LIVER FT






PT
10.7-13.7 sec
13.1
14.2
13.6
13.0
13.4
INR
1.0-1.24
1.1
1.2
1.1
1.1
1.1
APPT
25-40 sec
28.8
29.2
24.3
21.5
23.6







CARDIAC ENZYMES






AST
1-37U/L
148
1078
661
426

LDH
50-150U/L
659
1117
844
969

CK
0-130U/L
40
103
73
58








ABG






pH
7.35-7.45
7.36
7.38
7.4
7.42
7.46
PO2
75-100 mmHg
56
125
131
109
94
PCO2
35-45 mmHg
26.6
35
39
41
37
HCO3
24-28 mmol/L
9.0
21.8
24.2
26.6
26.9
SPO2
90-95%
68%
99%
98%
98%







J.      Drug Treatment in The Ward

Drug Name / Route
Dose / Frequency
Duration
Indication/Safety/Efficacy
Start-Stop Date
I.V Ranitidine 50mg
TDS
21/9 -

I.V Ceftriaxone 2g
BD
21/9 -

I.V Azithromycin 500mg
OD
21/9 -

I.V CaCl2 1g
TDS
21/9 – 24/9

I.V MgSO4 20mmol
STAT & OD
21/9 – 24/9

I.V Calcium Gluconate 10mmol
STAT & OD
21/9 – 24/9

I.V Cloxacillin 2g
QID
22/9 -



Date
21/907
22/9/07
23/9/07
24/9/07
25/907
26/907

General
Mixed metabolic acidosis and respiratory alkalosis.
Severe CAP
RBS 20.7 mmol/L
UO 30-60ml/hr
RBS 14.0 mmol/L
Still malaenic stool
Fibrinogen 137.9 mg/dL
D-dimer >0.2 mg/dL
UO 70ml/hr
Fibrinogen 137.9
D-dimer >0.2
Urine C & S no growth
RBS 10.1 mmol/L
Mycoplasma serology borderline positive.
RBS 4.7
Fibrinogen 149.1
D-dimer >0.2
RBS 12.1
UO 70-80 ml/hr
RBS 3.8
UO 80-100 ml/hr
Vital signs
BP
110/70
109/63
127/68
129/72
121/82
110/86
ABP






PR
150
133
107
95
92
102
RR






T
37.5
Spiking
37.5
Afebrile
37
37
CVP

17
15
15
15

O2Sat






CVS
ECG – sinus tachycardia





Plan/Action Taken
Intubated.
I.V Ranitidine 50mg TDS
I.V Ceftriaxone 2g BD
I.V Azithromycin 500mg OD
I.V CaCl2 1g TDS
I.V MgSO4 20mmol Stat & OD
I.V Calcium Gluconate10mmol Stat & OD
Insulin sliding scale
Fluid resuscitation
I.V Furosemide 10mg/hr
I.V Cloxacillin 2g QID
KIV S/C Heparin 5000 U BD.
I.V Tifacogin 14ml/hr for 96 hours via central line
Continue therapy
Continue therapy
Change I.V Ranitidine to 300mg ON
Off Insulin – start S/C insulin
Completed I.V Tifacogin infusion
Discharged to ward on 27/3.
Daily Progress Report

MICROBIOLOGY TESTS

Source
Date
Results
Sensitive to
Resistant to
Blood
24/9/07
Mycoplasma serology borderline positive.
-
-
















K.   Diagnoses/Provisional Dx/Acute/Chronic Medical Problems:

1)      Severe CAP – viral pneumonia?
                                      -  Atypical pneumonia?
1)      Sepsis secondary to CAP
2)      DM
3)      Compensated metabolic acidosis

Subscribe to receive free email updates: