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Mortality Conference. M/68 Date of Admission : 2009.07.07 Date of Death : 2009.07.22 2009.08.06 발표자 : R1 이소령 . Chief complaint. Cough (onset:4 MA). Present Illness.

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mortality conference

Mortality Conference

M/68

Date of Admission : 2009.07.07

Date of Death : 2009.07.22

2009.08.06

발표자: R1 이소령

chief complaint
Chief complaint

Cough(onset:4 MA)

present illness
Present Illness

45PY의 Ex-smoker로 내원 4개월 전 시작된 cough, sputum, dyspnea onexertion으로 외부병원 방문, Chest X-ray 소견에서 폐렴 의심된다 듣고 치료 받았으나 호전 없었음.

이에 6월 말 외부병원에서 chest CT시행하였고 폐암 의심되는 소견으로 further evaluation위해 입원.

past medical history
Past Medical History
  • DM/HTN/Tbc/CLD (-/-/-/-)
  • HIVD로 타 병원에서 수술 받음 (10YA)
  • Trauma로 인한 어깨 손상으로 수술 받음 (5YA)

Social History

Smoking : 45PY (내원 2개월 전부터 금연)

Alcohol : 소주 반 병, daily (약 50년간), 최근 금주함

systemic review
Systemic review

General weakness(+),

Fever/Chill (-/-), Wt loss (-)

Cough/Sputum/Rhinorrhea (+/+/-)

Sore throat(-)

Dyspnea (-) Orthopnea (-) DOE (+)

Chest pain/Palpitation (-/-)

Abdominal pain (-)A/N/V/D/C (-/-/-/-/-), H/M/H (-/-/-)

Urinary Symptom (-)

physical examination
Physical examination

V/S>129/80-85-22-37.0 SpO2 92%

G/A>not soIll-looking

Alert, orientation: T/P/P(+/+/+)

HEENT>

Pupil 3mm/3mm isocoric, prompt

Not anemic, anicteric

PI/PTH (-/-)

Not Dehydrated tongue

No palpable LN

physical examination1
Physical examination

Chest>

Symmetric expansion without retraction

Crackle at RLLF

RHB without murmur

Abdomen>

Soft flat. Normoactive bowel sound

T/RT(-/-)

L/S/K(-/-/-)

Back and Extremity>

CVAT (-/-), P/C/C (-/-/-)

initial lab findings
Initial Lab Findings

CBC:9500-13.2-207K (seg 75.4%)

E’:134-4.3-99-25 B/Cr 20/1.2

Ca/P 13.4/2.7 iCa 1.76

LFT:223-7.1/3.6-1.0-43-33/17 PT 65%

hsCRP:0.94

LDH 555

CEA 782

pft 09 7 9
PFT (09/7/9)
  • FEV1 3.65L (99%)
  • FVC 2.23L (88%)
  • FEV1/FVC 61%
  • DLCO :

poor cooperation

initial problem lists
Initial Problem lists

#1.Cough, sputum, DOE

#2.Abnormality on Chest imaging

…Consolidative mass, RLL

…Emphysematous lung, bullae

#3.Hypercalcemia

#4.Performance status ECOG 2

initial assessment
#1.R/O lung cancer

…combined pneumonia

#2.R/O underlying COPD

#3.Hypercalcemia

…d/t r/o paraneoplastic syndrome

…d/t r/o bone metastasis

Initial Assessment
initial plans
Initial Plans

#1.Tissue confirm by PCNB, staging w/u

#2.Consider antibiotics

#3.Hydration, bisphosphonate, PTH check

slide15

HD#1 -3

HD#1-3

S> cough, sputum, whitish/blood tinged.DOE

O> Room air state, SpO2 94-98% RR 22-24

ABGA 7.458-33.4-66.0-24.7 (sat 92.3)

PCNBx : non-small cell carcinoma / PTH <5

A> #1.Non-small cell lung cancer

#2.Hypercalcemia

P> FDG-PET시행

Pamidronate 투여

slide17

HD#4

HD#4

S> F/C (+/+) C/S (+/+) dyspnea (+) BTS (+)

O>V/S 111/73-115-24-38.8 (SpO2 88%)

Room Air ABGA 7.487-26.4-67.8-22.7 (sat 93.2%)

O2 5L공급하고 SpO2 96%이상 유지, RR 24

CBC 10790-12.4-145K (seg 90.4%) CRP 4.77

D-dimer 36.71

slide18
O>

FDG-PET : malignancy in consolidative mass in RLL

with suggestive of LNs metastasis in rt. Hilar, mediastinal area

with suggestive of liver & skeletal metastases

A>

#1. Non-small cell lung cancer, stage IV

#2. r/o pneumonia

#3. r/o pulmonary embolism

P>

#1. HMO transfer

#2. antibiotics start

#3. CT chest pulm. A + deep vein 시행

#4. consider LMWH

HD#4

slide20

HD#5-6

HD#5-6

S> F/C (+/-), cough (+) sputum (+) : whitish

fever 있을 때 두통 동반된다 함.

O> neck stiffness (-)

O2 demand 5L → 2L, SpO2 98%, RR 22-24

CBC 6500-11.7-152K (seg 75.7%) CRP 5.71

Ca/P 9.3/2.3

P> antibiotics 유지

slide21
O>

B/Cx, Sputum Cx : no growth

Pathology confirm> Favor Squamous cell carcinoma

A>

#1. pneumonia

#2. lung cancer stage IV (SqCC, M/bone, liver, LNs)

#3. intermittent headache

…r/o brain metastasis

P>

#1. antibiotics (piperacillin/tazobactam + levofloxacin)

#2. consider palliative chemotherapy

#3. consider Brain imaging

HD#7-8

slide22
S> F/C (+/-), cough (+) sputum (+) BTS (+)

O> V/S 105/65-90-24-37.5 (SpO2 93% on O2 4L)

CBC 10160-12.0-234K (seg 66.8%) CRP 5.79

CXR : Decrease in extent of consolidation in RLL

Brain MRI : no evidence of metastasis

P> antibiotics 유지

HD#9-11

HD#9-11

slide23
S> F/C (+/-), cough (+) sputum (+) BTS (+)

O> V/S 112/69-98-22-37.7 (SpO2 93% on O2 4L)

P> antibiotics 유지

palliative GP#1 start

94W transfer

HD#12

HD#12

slide24
S> F/C (-/-), cough (+) sputum (+)

O> V/S 102/67-86-22-36.0 (SpO2 93% on O2 4L)

ABGA 7.359-36.7-64.6-20.8 (sat 91.5%)

CBC 16120-10.0-177K (seg 92.6%) CRP 1.47

CXR : RLL consolidation의 큰 변화 없음

P> antibiotics 유지

supportive care

HD#13-14

HD#13-14

slide25
S> F/C (-/-), cough (+) sputum (+)

컨디션 좋다.

O> V/S 120/79-93-24-37.0 (SpO2 90% on O2 4L)

O2 4L ABGA 7.394-33.5-58.5-21.2 (sat 88.5%)

P> antibiotics 유지

(continued)

HD#15

HD#15

slide26
오후부터 dyspnea 호소하면서 O2 demand 증가

21:00 O2 4L SpO2 78% → O2 6L SpO2 91% RR 20-24

23:00 O2 6L ABGA 7.440-24.6-44.5-19.1 (sat 78.6%)

HD#16

01:00 V/S 105/74-109-30-35.7

O2 6LSpO2 83% → O2 7L 92%

10:00 O2 7L SpO2 77% RR 30, severe dyspnea호소

11:45 O2 10L, RR 28 → O2 12L

13:00 r/o pulmonary embolism 위해

D-dimer 및 Chest CT시행

D-dimer 5.12, CT소견 (continued)

HD#15-16

slide28
O>

CBC 18400-10.7-26K (seg 92.5%)

E’ 131-4.3-97-17 BUN/Cr 24/1.1

LFT 239-6.7/2.9-2.7-104-76/48

CRP 3.30

PT 48% aPTT 45.6 Fibrinogen 68

호흡기 내과 consult >

Recommend

-> O2, antibiotics (tazocin+levofloxacin iv)

-> ventolin/atrovent nebulizer, aminophylline iv

- if needed, elective intubation & MV support, ICU monitoring

(continued)

HD#16

slide29
15:00 O2 12L SpO2 77% RR 32→ O2 full

15:10 O2 full SpO2 check잘 안됨

RR 34 severe dyspnea 호소

15:20 Respiratory arrest

맥박 촉지 되지 않음

CPR start

ABGA 6.943-38.2-48.0-7.4 (sat 50.4)

15:32 intubation

16:05 expire

HD#16

cause of death
Cause of Death

#1. Respiratory failure

…d/t Pulmonary thromboembolism

…d/t Pneumonia aggravation, underlying emphysematous lung

#2. r/o Sepsis