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病歷號碼:16771490 性別:

姓名:5

床號:K763D 年齡:82

Chief Complains:

1.SOB, aggravated in recent one week

2.L't lower leg cyanosis with pain in recent 2-3 days

Present Illness:

This 83 y/o male with chronic lung disease suffered from SOB (aggravated in recent one week) and L't lower leg cyanosis with pain in recent 2-3 days.

This time, he visited our ER because of above reason, and there CxR showed bil. emphsematous change. At usual time, he visited 田中仁和H. and taked medicines for controlling the chronic lung disease (for few years). Shortness of breath was noted in past few years, and SOB was more severe in recent one week. There was cough with sputum sometimes. L't lower leg cyanosis was noted and cold sensation over all extremities was noted.

Under the suspection of DVT and COPD with AE, he admitted for further evaluation and management on 89-8-16.

Personal History:

1. smoking(+): 1-2 PPD for more than 60 years

2. alcohol drinking(+)

3. Medication: drugs form 田中仁和H.

4. Allergy history: denied

Immunization:

1. Parainfluenza vaccination (-).

2. Pneumococcus vaccination (-).

Past History:

1. Denied major systemic disease such as diabetes mellitus, hypertension,etc.

2. Denied any major operation history.

3. COPD

Systems Review:

1. General conditions:

fever(-), general malaise(+), body weight loss(-), chills(-)

2. HEENT: normal

3. Neck:

JVE(-), lymph node(-)

4. Respiratory:

cough(+), sputum(+), chest pain(-), hemoptysis(-), dypnea(+), SOB(+)

5. CV:

palpitation(-), DOE(-), tachycardia(-), bradycardia(-),arrhythmia(-),

chest tightness(-), orthopnea(-)

6. GI:

anorexia(-), nausea(-), vomiting(-), diarrhea(-), constipation(-),

dysphagia(-), heartburn(-), hematemesis(-), abdominal pain(-),

abdominal tenderness(-), abdominal distension(-), melena(-)

7. GU:

frequency(-), urgency(-), incontinence(-), dysuria(-), nocturia(-),

hematuria(-), polyuria(-), oliguria(-), abnormal discharge(-)

8. Endocrine:

moon face(-), weight change(-), hirsutism(-), polydipsia(-),

decreased libido(-)

9. Musculoskeletal:

muscle atrophy(-), involuntary movement(-), L’t lower leg pain (+),

limitation of ROM (-)

10. Mental status:

swing of mood(-), anxiety(-), memory loss(-)

11. Hematological:

cyanosis(+), pale sclera(-). petechiae(-), ecchymosis(+)

12. Skin:

itching(-), rash(-), ulcer(-), abnormal pigmentation(-)

Physical Exam:

General appearance: chronic ill-looking, weakness(+)

Cons: clear, E4M6V5

Vital sign: TPR: 37/100/25 BP: 129/69mmHg

HEENT: Conj: mild pale Sclera: anicteric

Neck: supple, no LAP, no JVE

Thyroid: N.P.

Axillary: no LAP

Chest: symmetric expansion, breathing sound: bil. moderate wheezing

Heart: RHB without murmur

Abd: soft and flat, tenderness(-) , no rebounding pain

normoactive bowel sound, Liver/spleen: impalpable, no palpable mass

Inguinal area: no LAP

Ext: freely movable, no pitting edema

Impression:

1.R/O DVT

2.COPD with AE

Plan:

1.use heparin

2.keep airway: use bronchodilator, aminophylline and steroid

3.supprotive Tx

4.F/U ABG to decide O2 supplyment amount

Hospital course:

8/16 COPD - SOB - on endo - RICU

8/17 empiric antibiotics use

heparin for l't leg DVT

8/18 bed-side heart echo: mild TR,MR

thrombolytic therapy

fever r/o L't foot gangrene

8/21 foley

8/23 biopsy:L’t foot cellulitis with necrosis

8/28 ECG show:sinus tachycardia,tall T wave

8/31 fragmin used for L't leg gangrene

9/3 prokinetics used for ileus

L't foot gangrene s/p B-K amputation

9/5 A-K amputation of L't foot

9/6 Keep antibiotics with pipril+Tobromicin

9/10 no fever

9/11 Venturi mask used

hyponatremia

hyperkalemia cause?

9/13 RICU, asthma attack

No used NSAID,ACEI,Aldactone since 8/16

Used heparin during 8/16~8/31

Lab Summary

BI

  8/16 8/21 8/28 9/4 9/11
Total Protein 7.2 4.8 5.3 5.3 6.8
Albumin 3.9 2.3 2.7 2.6 3.1
A/G 1.2 0.9 1.0 1.0 0.8
Cholesterol 215        
Triglyceride 62        
Uric Acid 9.3        

CS

8/16 Sputum: Haemophilus influenzae blood: no growth

8/17 Sputum: Gram stain G(+)Coccu urine: no growth

8/19 Pus: Enterococcus, Proteus mirabilis, Pseudomonas aeruginosa

8/31 Pus:Proteus mirabilis blood: no growth

HE

  8/15 8/17 8/21 8/24 8/28 8/31 9/2 9/4 9/5 9/7 9/11 9/14
WBC 13.1 14.3 17.6 13.9 14.6 23.7 19.2 22.1 24.7 22.9 29.6 24.5
RBC 4.89 4.56 3.46 3.45 2.82 2.59 2.73 2.79 3.21 3.35 3.28 3.31
HGB 15.8 14.6 11.1 11.1 9.1 8.4 8.6 8.7 10.0 10.8 10.6 10.7
MCV 97.6 98.2 97.9 96.6 95.6 96.3 97.9 95.8 95 94.6 94.6 94.7
Platelet 267 209 236 484 502 463 517 528 516 492 476 516
MCHC 33.2 32.5 32.8 33.2 33.7 33.4 32.3 32.6 32.8 34 34.3 34.2
MCH 32.4 32.0 32.2 32.0 32.3 32.2 31.7 31.2 31.2 32.2 32.5 32.4
HCT 47.7 44.8 33.9 33.3 26.9 25.0 26.7 26.7 30.6 31.7 31.1 31.4
N-Seg 75.6 88.9 89 85 86 94 94.9 89   84 84 86
Baso 0.8 0.1 1       0.0          
Eosin 0.1 0.0   1 2   0.1          
Mono 18.3 6.3 6 11 2 4 2.7 5   8 4 4
N-Band     1   1 1       2 2  
Metamyelocyte     1   2           2 1
Myelocyte         2 1       3 3 6
Atypical Lym               1        
Lymph 5.2 4.7 2 3 5 0 2.3 5   3 5 3
CRP         4.49              

 

 

  8/16 8/17 8/18 8/19 8/21 8/22
Pro. Time 11.4         10.4
ISI 1.02         1.02
I.N.R. 1.10         1.00
N.C. 10.4         10.4
APTT 29.5         33.4
Fibrinogen 285.4 289.6 294 365.9 430.5 430.5
D-dimer <250 500 250 1000 1000 1000

SC

  8/15 8/16 8/18 8/25 8/29 8/30 9/11 9/13
PH 7.277 7.210 7.421 7.431 7.376 7.292 7.368 7.391
PCO2 64.2 52.6 40.7 45.8 41.3 57.8 39.8 45.7
PO2 75.6 95.2 77.4 84.6 132.5 234.6 84.2 82.3
B.E. 0.7 4.4 1.3 4.7 1.5 0.5 2.7 1.6
HCO3 29.2 30.8 25.9 29.8 23.7 27.3 22.4 27.1
CO2tot 31.2 32.4 27.1 31.2 24.9 29.1 23.6 28.5
O2Sat 92.8 97.3 95.6 96.8 98.9 99.7 95.8 96
  8/16 8/17 8/21 8/24 8/28 8/31 9/2 9/4 9/7 9/11 9/12 9/13 9/14
Na 134 134 120 125 124 133   130 127 123   126 125
K 4.5 4.0 4.0 3.9 4.7 4.6   4.8 4.9 6.0 5.0 5.1 4.1
Glucose(spot) 118                        
B.U.N. 35.0 29.9 12.1 15.1 21.2 23.8   25.9 23.5 39.4     29.8
Creatinine 1.3 1.0 0.6 0.6 0.6 0.6   0.9 0.8 0.9     0.6
GOT 53                        
GPT 26                        
Amylase             42            
Una                   73      
Uk                   39.4      
Ucl                   77      
Cl                     92    
Posm                     285    
Uosm                     475    

UR

  8/17
Sp.Gr. 1.025
Occult Blood +++
PH 6.0
Protein >300
Urobilinogen 1.0
WBC esterase +/-
Bacteria +/-

D/D of hyperkalemia

1.Pseudohyperkalemia

檢體產生溶血、延遲將血清與紅血球分開、和止血帶放置過久的時候

2.Transcellular K+ shift(Redistribution)

3.Oligouria renal failure Potassium retention (Ccr<20ml/min)

MaleCcr=(140-age)*BW/72*Pcr

GFR<10-15ml/min

4.Assess K+ secretion(TTKG>10) TTKG=( Uk+ * Posm)/( Pk+ * Uosm)

TTKG=transtubular K+ concentration gradient

decreased distal flow

當濾過物質減少,Na+濾過減少,則在遠端Na+濃度低,則Na+-K+交換inactiveK+loss減少

5. Assess K+ secretion(TTKG<5)

response to 9a -fludrocortisone

5-1 TTKG>10

5-2 TTKG<10 Hypotension - high renin and aldosterone

5-3 TTKG<10 Hypertension - low renin and aldosterone

Anion gap: Na-Cl-HCO3

Urine anion gap: U NA+U K-U Cl >0 low urine NH4+

9/12

Mild metabolic acidosis

TTKG=39.4*285/6.0*475=3.94

Anion gap=123-92-22.4=8.6

UAG=73+39.4-77=35.4

Suspect hypoaldosteronism(low BP,Na+ wasting)

R/o Primary adrenal insufficiency

R/o Type 4 RTA(low gap metabolic acidosis,positive urine AG,hyperkalemia)

Treatment

重度高血鉀: >7.5mEq/L

中度高血鉀: 6.5~7.5mEq/L

輕度高血鉀: 5.5~6.5mEq/L

 

  1. 用鈣(calcium gluconate)來拮抗高K+造成的心率不整
  2. Digitalis toxicity危險:用digitalis antidate--MgSO4
  3. 緩解後用Sodium polystyrene sulfonate(Kayexalate),使Na+-K+交換 in the GI tract,加Sorbitol造成diarrhea加速K+GI excretion
  4. 若達透析標準,用透析降血K+
  5. 用轉移的方式:Glucose + insulin / NaHCO3
  6. b 2-adrenergic agonists: promote cellular uptake of K+
  7. loop and thiazide diuretics: may enhance K+ excretion if renal function is adequate
  8. 排除藥物引起的,疾病引起的要限制飲食,矯正代謝性酸中毒。
  9. mineralocorticoid replacement therapy(with fludrocortisone at a dose of 0.05 to 0.2 mg/day)for primary adrenal insufficiency

 

9/12 輕度高血鉀

Ca2+-gluconate

Kayxalate

insulin 10u + 50% G/W