Case Acute Shortness of Breath: ICM 2

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Case Acute Shortness of Breath: ICM 2

A-58 year-old-woman, Mrs.Shorta, admitted to emergency department complaining


acute shortness of breath and cough with purulent sputum and fever since 6 days and worsen in
the last 2 days. On further questioning, she does had diabetes and didn’t take the oral anti
diabetic regularly. No history of hypertension. she has a 35–pack-year smoking history and

continues to smoke but has recently “cut down” her cigarette use. She uses bronchodilator
inhalers only “as needed.” She received a course of antibiotics for an exacerbation of her
chronic obstructive pulmonary disease ∼2 months ago, but she does not remember the
name of the antibiotic.

On examination, The patient appears uncomfortable. The following observations were


made: Temperature: 37.9°C; Pulse: 105 beats/min; Blood pressure : 140/90 mmHg, Oxygen
saturations 90% on 10 lpm non rebreathing mask, Respiratory rate 40 breaths/min. There was
retraction, on chest auscultation she had rhonki in both lungs. A few wheezes are heard only

on forced expiration. Abdominal examination was remarkable. No pitting edema was found

Investigation results: Chest X-ray showed; ECG : sinus tachycardia. Arterial blood gases
showed : pH 7.47; pO2 62 ; pCO2 : 48; HCO3: 20 mmol/L; BE : +2, SpO2: 91%, FiO2 80%.

The patient's laboratory test results are as follows: hemoglobin level, 14 g/dL;
hematocrit, 42%; WBC count, 19,000 cells/µL with 85% neutrophils 9% lymphocytes; and
platelet level, 110,000 cells/µL. Electrolyte levels are as follows: Na+, 132 mg/dL; K+, 3.8
mg/dL; chloride, 115 mg/dL; The patient's blood urea nitrogen (BUN) level is 35 mg/dL, and
her creatinine level is 1.2 mg/dL eGFR 80. SGOT 22 SGPT 20, hsCRP 206, RBG 320 mg/dl.

Mrs Shorta was admitted to mechanical ventilation. she was given intravenous fluids

and empirical intravenous ceftriaxone, azithromycin and high dose corticosteroid through a
peripheral vein. Sputum and blood culture was obtained. She was discharged with follow up
in diabetes and COPD treatment. She was given pneumococcus and influenza vaccine and stop
smoking management.

1
Figure 1. Shorta,, 56 years old female, chest xray on admission

Please discuss these following things :

1. What is your differential diagnosis and what is your working diagnosis?


2. What are the data you need and find in this case to support your diagnosis?
3. What are the clinical conditions that causing ARDS?
4. What are the pathophysiology of ARDS?
5. What are the therapy for this patient?

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