Mortality-conference-2022.03.24 FINAL (自動儲存)
Mortality-conference-2022.03.24 FINAL (自動儲存)
Mortality-conference-2022.03.24 FINAL (自動儲存)
Date: 2022.08.31
Supervisor: VS 高浩倫醫師
Speaker: PGY2 許誌元
Patient Information
Name: 張 O 花
Gender: Female
Age: 77 year old
ID: 1780833
Admission: 2022.02.05
Expired: 2022.02.11
2
Chief Complaint
3
Present illness
2009/01- Frequent visit ER and CHE OPD due to shortness of breath and
2017/08 persistent cough with sputum diagnosed with bronchial
asthma Long-term follow up in CHE OPD under steroids.
2012/07- Intermittent bilateral hand joint painful sensation for one month.
The symptom exacerbated especially in the morning and during
increasing daily activity.
Visited RIA OPD diagnosed with rheumatoid arthritis
Long-term follow up in RIA OPD under steroids.
4
Present illness
2022/01 Chest discomfort last for one month. visit CHE OPD in 國
泰 hospital on 1/22. X-ray: pneumonia. Oral antibiotics
were given and the patient's symptoms got improved.
5
At TSGH ER
Blood routine, BGA Blood biochemistry, Urine routine
pH 7.443 mmHg BUN 37 mg/dL CK 27 U/L
PaCO2 30.8 mmHg Creatinine 1.1 mg/dL Lipase 47 U/L
PaO2 157.3 mmHg AST 68 U/L Glucose 179 mg/dL
HCO3 20.6 mmol/L ALT 27 U/L Pro-BNP 561.5 pg/mL
WBC 3.41 103/uL Total 0.9 mg/dL Troponin-I 26 pg/mL
bilirubin
RBC 385 106/uL Na 133 mmol/L D-dimer 1.75 mg/L
Hb 11.8 g/dL K 5.6 mmol/L Urine WBC 0-2
Platelet 80 103/uL Lactate 2.3 mmol/L Urine RBC 0-2
Neutrophil 78.0 % Ammonia 63 ug/dL Epith. cells 2-5
Lymphocyte 17.6 % PCT 0.36 ng/dL Bacteria 2+
6
Present illness
7
Present illness
8
Present illness
Presence of brain
atrophy. No acute infarct
or cerebral hemorrhage
is identified.
9
Electrocardiography
10
Present illness
2021.
In ER:
02.05 1. Oxygen supply: simple mask 8L/min 6L/min
2. Antibiotics: Cravit 750mg IVA stat
3. Medason 40mg IVA
4. Foley 14Fr. Insertion
5. Insulin Actrapid 6U IVA + Dextrose 50% 60ml IVA +
Vitacal 20ml 1amp IVA
6. Blood culture
Admission
11
Past History
Systemic disease:
1. Rheumatoid arthritis 5. Hyperlipidemia
2. Bronchial asthma 6. Gout
3. Type 2 diabetes
4. Hypertensive cardiovascular
disease
Operation history:
1. 2009-07-01 Operative arthroscopy with shaving arthroplasty + partial
menisectmoy of medial meniscus, right knee
2. 2012-07-25 Operative arthroscopy with partial meniscectomy, right
knee
12
Personal history
Patient
• Occupation: retired
Information
• Traveling in recent 3 months: denied
• Contact history: denied
• Cluster history: denied
• Alcohol/betel nut/cigarette: denied
• Allergy to food/drug: bamboo, beans, seafood
13
Family history
HCC
14
Review of system
15
Physical examinations
Vital signs:
TPR: 37.6 ℃/ 122 次 / 24 次
HEENT:
BP: 145 / 98 mmHg
no cervical lymphadenopathy, no oral
SpO2: 99%
ulcer or petechiae
Conscious: alert
GCS: E4V5M6
Heart: regular HB , no murmur , no
Chest: heave or thrill
Well expansion, coarse
breathing sound, no rhonchi,
no wheezing, bilateral Skin: Senile skin turgor
crackles
Abdomen:
Flat Extremities:
Normoactive bowel sound no pitting edema, normal ROM
No tenderness
No rebounding pain 16
Tentative diagnosis
1. Community-acquired pneumonia, bilateral upper and
lower lobes.
2. Bronchial asthma
3. Rheumatoid arthritis under monthly golimumab (Simponi)
and immunosuppressants
4. Hypertensive cardiovascular disease
5. Hyperlipidemia
6. Type 2 diabetes
7. Gout
17
Hospital Course
18
Hospital Course
2022/02/05 Empirical antibiotic treatment:
Betamycin 3.375g Q6H IVD
Klaricid XL 500 mg 1tab QOD PO
Oxygen: simple mask 6L/min nasal cannula 3L/min nasal cannula 3.5L/min
SpO2: 90-98%
GCS : E4V3-5M6
PCR test(blood): P. jirovecii, HSV and CMV
Blood antigen screen for Cryptococcus
Antibody screen for Mycoplasma
Sputum culture and acid-fast stain x3
2022/02/07 Desaturation with SpO2 dropped to 88% at 12:53. Blood gas analysis,
12:53 blood routine, biochemistry and blood culture.
Oxygen: nasal cannula 4L/min simple mask 6L/min simple mask 8L/min
SpO2 : 94-95%
Consult INF for antibiotics adjustment Add Meroxin 0.5G Q12H to replace
Betamycin 3.375g Q6H IVD
Suggest endotracheal tube intubation refused by the family
20
Laboratory examinations
02/07 06:10
Blood routine, biochemistry and urine routine
WBC 2.51 103/uL Na 137 mmol/L Total calcium 9.5 mg/dL
Hb 9.5 g/dL K 4.2 mmol/L Mg 1.8 mg/dL
Platelet 57 103/uL BUN 49 mg/dL Urine WBC 0-2
Neutrophil 84.8 % Creatinine 1.5 mg/dL Urine RBC >100
Lymphocyte 9.2 % AST 48 U/L Epith. Cell 2-5
CRP 3.09 mg/dL ALT 21 U/L Bacteria Not found
Albumin 2.4 g/dL Cl 110 mmol/L Occult blood 3+
HbA1c 7.7 % Uric acid 5.5 mg/dL
21
Radiologic findings
2022/02/05 2022/02/07
22
Hospital Course
2022/02/07 Follow up blood routine, biochemistry, urine routine, chest X-ray
06:10 Oxygen: nasal cannula 3L/min nasal cannula 4L/min
SpO2: 90-92%
GCS : E4V4M5-6
Chest X-ray: bilateral pneumonia with mild improvement
Low urine output Add Rasitol 20mg QD IV
Arrange urine culture
2022/02/07 Desaturation with SpO2 dropped to 88% at 12:53. Blood gas analysis,
12:53 blood routine, biochemistry and blood culture.
Oxygen: nasal cannula 4L/min simple mask 6L/min simple mask 8L/min
SpO2 : 94-95%
Consult INF for antibiotics adjustment Add Meroxin 0.5G Q12H, DC
Betamycin 3.375g Q6H IVD
Suggest endotracheal tube intubation refused by the family
23
Laboratory examinations
02/07 14:10
Blood routine, biochemistry, gas analysis and infection survey
WBC 3.19 103/uL Na 137 mmol/L
Hb 10.3 g/dL K 4.3 mmol/L
Platelet 59 103/uL BUN 48 mg/dL
Neutrophil 86.5 % Creatinine 1.5 mg/dL
Lymphocyte 8.8 % pH 7.343
CRP 2.79 mg/dL PaCO2 33.2 mmHg
AST 56 U/L PaO2 78.7 mmHg
ALT 28 U/L HCO3 17.6 mmol/L
P. jirovecii Negative
PCR(blood) CMV Negative
HSV Negative
Antigen
Cryptococcus Negative
screen(blood) 24
Hospital Course
2022/02/08 Follow up blood routine, biochemistry, SMA and vein gas analysis
Oxygen: simple mask 8L/min simple mask 10L/min
SpO2: 97-99% 93%
GCS: E4V4-5M6
NG tube insertion due to poor intake chest X-ray follow up
DNR was signed except drug(DNR 除藥 ).
Albutein 50ml QD IV was added.
Patient restraint PRN was agreed due to irritation and attempt to get off the
mask.
25
Laboratory examinations
02/08 05:57
Blood routine, biochemistry, SMA and vein gas analysis
WBC 3.33 103/uL Na 139 mmol/L ALP 75 U/L
Hb 9.8 g/dL K 4.0 mmol/L Total bilirubin 0.7 mg/Dl
Platelet 56 103/uL BUN 46 mg/dL Total protein 6.0 g/dL
Neutrophil 87.4 % Creatinine 1.5 mg/dL HbA1c 7.9 %
Lymphocyte 7.8 % Albumin 2.6 g/dL pH 7.380
CRP 4.19 mg/dL Cl 109 mmol/L PvCO2 33.6 mmHg
AST 58 U/L Total calcium 9.4 mg/dL PvO2 65.2 mmHg
ALT 28 U/L IP 2.9 mg/dL HCO3 19.4 mmol/L
26
Radiologic findings
2022/02/05 2022/02/07 2022/02/08
27
Hospital Course
2022/02/08 Follow up blood routine, biochemistry, SMA and vein gas analysis
Oxygen: simple mask 8L/min simple mask 10L/min
SpO2: 97-99% 93%
GCS: E4V4-5M6
NG tube insertion due to poor intake chest X-ray follow up
DNR was signed except drug(DNR 除藥 ).
Albutein 50ml QD IV was added.
Patient restraint PRN was agreed due to irritation and attempt to get off the
mask.
28
Hospital Course
2022/02/09 Oxygen: Non-rebreathing mask 15L/min Non-rebreathing mask 12L/min
SpO2: 94-98%
GCS: E4V3-4M6
Add Medason 40mg in case of interstitial lung disease.
Sputum suction for TB culture was arranged.
Few clot through NG tube drainage Pantoloc 40mg IV ST 、 Vitamin K1 10mg
IV ST 、 Vitamin C 100mg IV ST 、 Hemoclot 500mg IV ST Gastric OB 3+
Consult RIA to rule out rheumatoid arthritis-related pulmonary disease.
30
Radiologic findings
2022/02/08 2022/02/09
31
Hospital Course
2022/02/10 Oxygen: High-flow nasal cannula 60L/min + Non-rebreathing mask full
SpO2 : 77-82%
GSC: E3-4V3M5 E2M3-4V1 E1V1M3
Shortness of breath Morphine 3mg IV ST
Tracheal aspiration was collected for acid-fast stain and TB culture
Acid-fast stain: moderate(3+) Negative-pressure isolation
Tracheal aspiration culture: Staphylococcus aureus(Methicillin-sensitive
staphylococcus aureus)
32
Aerobic culture of tracheal aspiration
33
Hospital Course
2022/02/10 Oxygen: High-flow nasal cannula 60L/min + Non-rebreathing mask full
SpO2 : 77-82%
GSC: E3-4V3M5 E2M3-4V1 E1V1M3
Shortness of breath Morphine 3mg IV ST
Tracheal aspiration was collected for acid-fast stain and TB culture
Acid-fast stain: moderate(3+) Negative-pressure isolation
Tracheal aspiration culture: Staphylococcus aureus(Methicillin-sensitive
staphylococcus aureus)
34
Desaturation to 75%
Desaturation to 88% NRM Add HFNC(FiO2: 92%)
At admission: N/C simple mask
simple mask (FiO2: 45%)
6L/min(FiO2: 45%)
Desaturation to 86%
simple mask NRM(FiO2: 80-90%)
35
Radiologic findings
36
WBC counts Platelet
37
CRP level D-dimer
38
Pro-BNP Troponin I
39
40
Cause of death
41
Final diagnosis
1. Pneumonia, bilateral upper and lower lobes(Methicillin-susceptible
Staphylococcus aureus and pulmonary tuberculosis) with acute
respiratory failure and multiple organ dysfunction syndrome including
acute decompensated heart failure, acute renal failure, disseminated
intravascular coagulation, and upper gastrointestinal bleeding.
2. Rheumatoid arthritis under monthly golimumab (Simponi) and
immunosuppressants
3. Bronchial asthma
4. Hypertensive cardiovascular disease
5. Hyperlipidemia
6. Type 2 diabetes
7. Gout 42
Review:
Tuberculosis
43
General principles
1. Approximately 1.7 billion people are infected with tuberculosis but less than
15% of them progress to active disease.
2. Increased prevalence of multidrug-resistant tuberculosis (MDR-TB,
resistant to both rifampin and isoniazid) is observed. A similar trend is also
noted for extensively drug-resistant tuberculosis (MDR-TB plus resistance
to fluoroquinolones and at least one of three injectable second-line
drugs).
3. Latent tuberculosis infection(LTBI) is a misnomer referring to. someone
who has infection but not disease(clinical and radiological evidence of
active disease)
44
Clinical presentation
45
Diagnostic testing
46
Primary
tuberculosis
47
Post-primary
tuberculosis
48
Miliary
tuberculosis
49
Conference
1. The Washington manual of medical therapeutics, 36th ed.
2. The Massachusetts general hospital handbook of internal medicine, 7th ed.
3. Interpreting chest x-ray: illustrated with 100 cases
4. Chest radiology: patterns and differential diagnosis, 7th ed.
5. Radiopaedia
50
Thank you for listening
51