Transcript Mortality_ConferenceJHK

Mortality Conference
Date of Admission : 2010.2.4
Date of Death : 2010.2.20
2010.3.25
발표자: R2 강지훈
Chief complaint
• F/89
• oral intake, poor
– Onset : 5DA
Present Illness
#1. rectal cancer로 2005.4 LAR 시행.
이후 본원 GS 외래 다니면서 NED.
#2. 2008.1 bifrontal area HA, anemia 나타나 신경과 입
원 치료 받다가 찍은 Chest CT 에서 r/o IPF, PFT에서
severe restrictive pattern으로 판단되어 r/o IPF로 본원
호흡기 내과 외래 다니기 시작.
Present Illness
#3. 2009.11.5 cough 심화되면서 ER 방문하였으나,
EGD 시행 후에 r/o cough d/t GERD으로 sx care 하
면서 호전.
#4. 2010.1.21 호흡기 내과 외래 방문하여 IPF에 대해
서 입원하여 w/u 하기를 권유 하였으나 환자분과
교수님과 상의하여 집에서 observation 하기로함.
Present Illness
#5. 15일전부터 대변은 보지 못했다고 하며, 약 1주
일 전부터 소변이 시원하게 나오지 않는다고 함.
또한 내원 5일 전부터 poor oral intake 보이고
general weakness 나타나 내원.
이에 2010/2/4 ER 방문함.
Past Medical History
DM/HTN/Tb/CLD (-/+/-/-)
rectal cancer로 2005.4 LAR
Social History
denial
Systemic review
G/W(++), E/F(-), F/C(-/-) HA/Dizz(-/-)
C/S/R(+-/+-/-), sore throat(-)
dyspnea(+-), palpitation(-),
chest discomfort(-) orthopnea (-)
A/N/V/D/C(+/-/-/-/+), H/M/H(-/-/-),
abdominal discomfort(-)
Urinary sx(+) : dysuria
Physical examination
G/A>
acute so ill-looking
not so alert and oriented: T/P/P(+/-/+)
HEENT>
L/R(++/++), isocoric prompt
anemic conjunctivae, anicteric sclerae
PI(-/-), PTH(-/-)
oral cavity: clear
sl. dehydrated tongue
no palpable cervical LAP
Physical examination
Chest>
symmetric expansion without retraction
coarse lung sound without rale and crackle
regular HB without murmur
Abdomen>
soft, flat NABS
T/RT(++/-) : RUQ
L/S/K(-/-/-)
Back and Extremities>
CVAT(-/-) P/C/C(-/-/-)
Initial Lab Findings
V/S >
122/66 - 82 - 20 - 35.2
ABGA : 7.473 - 43.4 - 90.3 - 31.1 - 97.4%
CBC : 14040 - 8.6 - 219k, ANC 12551
electro : 128/4.03/83.5/29.2
B/Cr : 38/0.8
LFT : 89 – 5.8/3.0 – 1.0 – 149 – 127/126
CRP : 37.0
pro BNP : 1032
CK/CKMB/TnI : 25/<0.5/<0.04
Initial Imaging
CAP>
Initial Imaging
* Chest CT >
Initial Imaging
* Abdomen CT >
Initial Imaging
* Abdomen CT >
Initial Problem list
#1. multi - loculated fluid collection in liver
- r/o liver abscess
- r/o liver mets.
#2. h/o rectal cancer
- s/p LAR 2005.4 -> NED
--> NED
#3. known IPF
#4. known HTN
#5. known GERD
Initial Plan
#1. PCD for liver abscess
Blood culture and empirical antibiotics
#3. consult to IMP for further w/u
#4.~ #5. continue medication
Hospital course HD #1-4
S> N/V, abd pain 지속적으로 호소함. Fever 지속적으로 남.
O> PCD fluid : R/W/p/l/o : (>1000/>1000/37/49/14)
t. pro : 4400mg/dl, LDH 53736
PCD culture : all S Klebsiella pneumoniae
B/C : (-)
CRP : 9.24 (2/7) <- 25.94 (2/5)
A> giant liver abscess
P> Antibiotics : ceftriaxone + MTNZ :2/4-2/8
Hospital course HD #5-8
S> abd discomfort 지속적으로 있음. Fever 는 조금 subside
2010/2/10 PCD drainage 양 급감하여 CT re evaluation and foley insertion
O> 2010/2/9 B/C : (-)
CRP : 6.88(2/11) <- 9.24 (2/7) <- 25.94 (2/5)
A> giant liver abscess
P> Antibiotics upgrade d/t sustained fever : imipenem : 2/9-2/12
2010/2/11 PCD tube check 하고 O2 need 증가하여 NP 6L로 증량
CT Imaging
* Abdomen CT >
Hospital course HD #8-11
S> 조금 편안해 한다.
A> giant liver abscess
P> Antibiotics change after IMI consult
ceftriaxone+ amikacin :2/12known IPF에 대해서 treatment 하지 않기로 함.
환자 보호자분과 면담하여 aggressive treatment는 하지 않기로 함.
Hospital course HD #11-14
S> 잠을 잘 못 자고 dyspnea 호소한다.
가만히 있을 때 saturation은 95% 정도 유지되지만, 조금이라도 움직이면 80%대까지
떨어진다.
O> ABGA : 7.434 – 54.3- 70.1 – 35.6 – 93.8% ( NP 6L/min )
CRP : 9.94(2/17) <- 6.88(2/11) <- 9.24 (2/7) <- 25.94 (2/5)
P> Antibiotics change after IMI consult
ceftriaxone+ amikacin :2/12-
Hospital course HD #14-16
S> O2 need increasing (2010/2/19 2PM : O2 facial mask full 로 change)
O> ABGA : 7.407 – 51.4 – 50.0 – 31.6 – 83.9% ( NP 6L/min )
CRP : 9.94(2/17) <- 6.88(2/11) <- 9.24 (2/7) <- 25.94 (2/5)
fever 감소 했다가 조금씩 오르는 양상
mental : drowsy
P> Antibiotics 유지 : ceftriaxone+ amikacin :2/12full supportive care
Hospital course HD #16
7A : O2 full 에서 saturation fluctuation 심함. (30%-100%)
10A : BP 81/45로 감소하고 saturation 간간이 측정 안됨.
11A : BP 측정 어려움.
12A20 : expire
Cause of death
#1. r/o sepsis
- r/o d/t liver abscess