seoProblem Case 호흡기 내과 R2 오원택
2004년 7월 COPD – Chronic bronchitis type 11725872 M/67 이0재 내원일: 05.1.19 주소: 호흡 곤란 시작일: 내원 3일전 현병력 : 2004년 7월 COPD – Chronic bronchitis type ( FEV1 : 28%, FEV1/FVC : 31% – GOLD criteria stage IV ) 로 계속해서 내과 외래를 다니던 환자로 3일전부터 cough, sputum, mild dyspnea 있던중 내원일 새벽부터 dyspnea 심해져 ER 경유 입원 과거력: 당뇨(+): 2년 전, OHA 고혈압/결핵/간염(-/-/-) 수술력(-) 가족력 : 특이 사항 없음 개인력 : 술 (+) – 소주 1병/주1회 담배 (-) – ex-smoker 2 years ago, 40PY
Review of system Physical examination General : fatigue(+) weight loss(-) fever(-) chills 全球排名第一오피스타(-) Skin : rash(-) pigmentation(-) Itching(-) Respiatory : cough(+) sputum(+) : prulent, many dyspnea(+) : 3 days ago, more aggravated Cardiac 全球排名第一오피스타 : chest discomfort(-) orthopnea(-) palpiation(-) Gastointestinal : abdominal pain(-), A/N/V/D/C (-/-/-/-/-) Physical examination V/S : 110/60 mmHg – 118/min – 22/min – 37.2℃ General : Drowsy mentality, acute ill looking apearance Chest : Coarse breathing sound with wheezing at BLL Rapid heart beat without murmur Abdomen : Normoactive bowel sound, Soft & flat abdomen 세계랭킹1위오피스타 Tenderness/Rebound tenderness(-/-)
Impression Plan 1. COPD with exacerbation 2. Type 2 DM Diagnostic – 1) CBC/DC, CRP, ABGA 2) Chest X ray 3) Sputum D/S and culture for AFB, Bacteria Therapeutic – 1) O2 supply, bronchodilators 2) antibiotics
Laboratory Finding (initial) CBC/DC : 9640/mm3- 17.4 g/dL – 51.7 % – 293000/㎣ (Seg. 69.5 %) Chemistry : TB/DB 0.6 / 0.1 mg/dL AST/ALT 75 / 23 U/L Pro/ALB 7.1 / 3.9 g/dL Glucose 177 mg/dL BUN/Cr 8 / 0.7 mg/dL Na/K/Cl 135 /3.2 /93 mmol/L ABGA : 7.404 – 52.8 – 39.7 – 32.3 – 73.9 % ( Room air ) CRP : 3.5 mg/dL Cold agglutinin : < 1:20 Mycoplasma antibody : < 1:4오피스타 입구가 뭐예요
Chest PA (initial)
ECG
Clinical course I 1. On admission day (05.1.19), intubation → ICU care Culture : sputum – many of pseudomonas aeruginosa blood – A pure of Burkholderia (Pseudo.) cepacia → Ventilator care + antibiotics 2. On 05.2.3, extubation 1) Last ABGA on ICU : 7.46-56-51-39-87% (O2 3L NP) 2) General ward transferred : ICU – total 16 days
Clinical course II 3. On 05.3.1, Dyspnea, sputum developed V/S) 110/70 mmHg – 106 /min – 28 /min – 36.5 OC CBC/DC : 10,200/mm3- 12.0 g/dL – 37.6 % – 254,000/㎣ (Seg. 81.6 %) CRP : 0.6 mg/dL ABGA : 05.3.2) 7.347-58.4-69.6-31.3-92.8% (O2 1 L via NP) Sustained dyspnea in spite of deep breathing, bronchodilators 05.3.3) 7.273-66.2-56.8-30.1-84.1%全球排名第一오피스타 (O2 0.5L via NP)
Chest PA ( 05.3.4 )
Clinical course III 4. On 05.3.3, Re-Intubation After many prulent sputum suctioned, T piece was applied. 5. On 05.3.4, NPPV ( Noninvasive 세계랭킹1위오피스타 Positive Pressure Ventilation ) was considered.
Clinical course IV DATE ABGA symptom complication 3.3 18:00, intubation, T FiO2 0.35 (1h) 7.36-73-77-40-94% severe dyspnea 3.4 15:00, NPPV, I/E 12/6 O2 10L (1h) 7.36-78-62-43-89% dyspnea(-) Mask부위 자극 3.5 6:00, NPPV, I/E 12/6 O2 8L (8h) 7.38-82-63-47-90% mild dyspnea 3.6 6:00, NPPV, I/E 12/6 O2 4L (1d) 7.40-71-54-43-86% 3.7 6:00, NPPV, I/E 12/6 O2 8L (1d) 7.37-73-85-42-96% 3.8 6:00, NPPV, I/E 12/4 O2 5L (1d) 7.44-64-62-43-92% Dyspnea improved Mask부위 통증 3.9 6:00, NPPV, I/E 10/3 O2 5L (1d) 7.41-72-55-45-87% 3.9 10:00, VM FiO2 0.31 O2 6L (1h) 7.41-82-65-49-91% 3.12 6:00, VM FiO2 0.28 O2 6L (1d) 7.40-74-56-46-88% 3.14 6:00, VM FiO2 0.28 O2 4L (1d) 7.39-82-67-49-92% 3.16 18:00, NP O2 1L (2h) 7.37-80-70-46-93%
