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APAT

The patient, a 50-year-old male smoker with a history of tuberculosis, presented with worsening dyspnea and was found to have empyema thoracis, pneumonia, and newly diagnosed diabetes. He required intubation and was being treated with antibiotics for empyema while undergoing further diagnostic testing and management of his heart failure and diabetes. His clinical team discussed continued treatment plans and monitoring for his various conditions.

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12 views

APAT

The patient, a 50-year-old male smoker with a history of tuberculosis, presented with worsening dyspnea and was found to have empyema thoracis, pneumonia, and newly diagnosed diabetes. He required intubation and was being treated with antibiotics for empyema while undergoing further diagnostic testing and management of his heart failure and diabetes. His clinical team discussed continued treatment plans and monitoring for his various conditions.

Uploaded by

rendererichmadarang
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Good day Doctor

This is Faith Jane A. Parba


First Year IM Resident

Respectfully referring Blue Service patient


APAT, ENER
50/M

Hospital Day 9
Ceftriaxone Day 4
Azithromycin Day 7
Clindamycin Day 1+1

Current Working Impression:


Acute Respiratory Failure Type I Secondary to Empyema Thoracis; Community Acquired
Pneumonia- High Risk (Hypoxia); Cor Pulmonale, LVH, Sinus Rhythm, Functional Class IV;
Chronic Obstructive Pulmonary Disease not in Acute Exacerbation; DM Type II- Insulin
Requiring, Newly Diagnosed

Chief Complaint: dyspnea


HPI:
Two months prior to admission, the patient had onset of productive cough associated with
exertional dyspnea and on and off bipedal edema. Sought consult with a private physician. Given
unrecalled medicines.
One month prior to admission, there was persistence of above symptoms, sought another consult
wherein chest x-ray done revealing: Pleural Effusion Right, Bilateral Pneumonia with cavity
formation in the right upper lobe- Koch’s Etiology considered. Admitted in a local hospital from
December 26- 31, managed as a case of Pneumonia and discharged after 5 days with the
following home meds: Spironolactone, Salmeterol + Fluticasone, Cefixime, Butamirate citrate
and multivitamins + buclizine.
In the interim, there was persistence of symptoms but was lost to follow up
On the day of admission, worsening of dyspnea prompted present consult and was subsequently
admitted.

Past Medical History: (+) History of PTB- 2019- Unable to complete 6-months treatment
(-) HPN, (-) DM, (-) BA
Family History: (+) DM, (-) HPN, (-) BA
Personal Social History: 30-pack year smoker; non-alcoholic beverage smoker
COVID History: Vaccinated with 2 doses of Sinovac; No history of Covid Infection

Review of Systems: (+) 2-pillow orthopnea, (+) occasional paroxysmal nocturnal dyspnea

Physical Examination:
Awake, Intubated with the following MV set up
AC mode
TV 450
Fi02 100
PEEP 5
RR 16
VTrig 1
Vmax 50
RAMP

GCS 11(E4V1M6)
Anicteric sclera, Pink palpebral conjunctiva, (-) neck vein engorgement
ECE, Decreased breath sound on both lung fields
AP, NRRR, no murmur
Soft, nontender abdomen,
Full Pulses, CRT<2 secs, (+) bipedal edema

Latest Laboratories:
01/25/2023
BUN 5.32
Creatinine: 54.52

(01/19/2023)
CBC + PLT: Hemoglobin 131
Hematocrit 0.46
RBC Count 6.74
WBC Count 3.36
Neutrophil 65
Lymphocytes 21
Monocytes 10
Eosinophil 4
Basophil 0
Platelet Count 132

Potassium 4.4
Magnesium: 0.72
Calcium: 2.07
Sodium: 140
Procalcitonin: 2.42 positive

01/17/2023
FBS- 8.24
Cholesterol: 2.10
Triglycerides: 0.70
HDL-C: 0.40
LDL: 1.38
VLDL: 0.32
Albumin: 27.83
Chest Xray (01/15/2023)
Bilateral pneumonia with consolidation
Minimal to moderate pleural effusion right
Chest Ultrasound (01/20/2023)
Consider Empyema thoracis with pleural thickening, right

1/21/23
Sputum GS/CS
Gram stain: few gram (+) cocci chain, pairs; Gram negative rods; <25 PMN/lpf, >10 Epithelial
cells

Blood CS 01/20/2023
Left arm – NEGATIVE AFTER 5 DAYS OF INCUBATION
Right arm - NEGATIVE AFTER 5 DAYS OF INCUBATION

ABG (1 hour post intubation)


ABG at MV
pH 7.26
pCO2 87
PaO2 255
HCO3 39
O2 sat 100%

Partially Compensated Respiratory Acidosis with More than Adequate Oxygenation

Plans:
Pulmo: Hooked to Mechanical Ventilator with the ff set up:
AC mode
TV 450
Fi02 100
PEEP 5
RR 16
VTrig 1
Vmax 50
RAMP
For CTT insertion
For Sputum Gene Expert

IDS: Ceftriaxone Day 4; Azithromycin Day 7; Clindamycin Day 1+1


With ultrasound finding of Empyema thoracis in the patient, plan to continue Ceftriaxone
2g IV OD and Clindamycin 600mg IV Q8 as this is the first line treatment for empyema in
adult base on national antibiotic guidelines. Will discontinue azithromycin.
For pleural Fluid Studies: Chemistry (Protein, LDH, Sugar)
GSCS, AFB, KOH
Cell count, diff count
Cell cytology, cell block
TB culture.

Endo: Patient has not been known to be diabetic but his latest FBS result showed a value of 8.24.
Hence patient was on CBG monitoring three times a day pre meals with the highest CBG
value of 187. Patient is on the following RI rescue doses:
Hyperglycemia: CBG: 180- 220 give RI 4 units SQ
221-260 give RI 6 units SQ
261-300 give RI 8 units SQ
>300 give RI 10 units SQ
Hypoglycemia: CBG: < 80 give 15cc D5W
CBG < 70 give 25cc D5W
CBG < 50 give 50cc D5W
Since we are considering cardiac problem in this patient, we Plan to start Dapagliflozin, a
Sodium–glucose cotransporter 2 (SGLT2) inhibitors. Sodium–glucose cotransporter 2
(SGLT2) inhibitors reduce the risk of hospitalization for heart failure and cardiovascular
death among patients with chronic heart failure and a left ventricular ejection fraction of
40% or less.

Cardio: Based on patient’s 2-month history of exertional dyspnea, edema, 2-pillow


orthopnea and PND, we are considering heart failure for this patient. Latest ECG of this
patient showed Sinus rhythm with Right Atrial enlargement, Right Axis Deviation, poor r
wave progression. Patient is still for 2d Echo. Current meds: Ivabradine 2.5mg/tab, 1 tab
OD

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