STUDI KASUS B

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 21^st 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