SILLIMAN UNIVERSITY MEDICAL SCHOOL

SUBMITTED TO:
SUBMITTED BY:
I. REPRESENTATIVE CASE
IDENTIFYING DATA: This is J.C. a 56 year old male, married, Jehova’s Witness, from Junob, Dumaguete City, who was admitted at SUMC for
the first time. He was referred to the Pulmonology Service from department of Surgery because of cyanosis
CHIEF COMPLAINT: Abdominal RLQ pain
HISTORY OF PRESENT ILLNESS: He was apparently well until 4 day PTA, when he complained of tolerable epigastric pain associated with
nausea and low grade fever. A day later, he vomited previously taken food and he felt increasing generalized abdominal pain, more localized at
the right lower quadrant. He took buscopan and kremil-s, which provided transient relief. A few hours PTA, he sought admission at the
hospital because of increasing RLQ pain accompanied with high grade fever and chills. There was no headache, diarrhea and dysuria
PAST MEDICAL HISTORY: Unremarkable
FAMILY HISTORY: Unremarkable
PERSONAL AND SOCIAL HISTORY: He smokes 3-5 sticks of cigarette/day for the last 40 year. He drinks alcoholic beverages only on special
occasions. He works with the DepEd as a public school teacher and plans to retire at age 60.
REVIEW OF PHYSICAL EXAMINATION
SYSTEMS
Unremarkable General Survey: Ambulatory but leans forward and to the right, splinting his right lower abdomen, anxious looking
appears appropriate for his age
Vital Signs: BP: 90/60 mmhg HR: 110/min
RR: 24/min Temp: 39.2 C
HEENT: Pinkish conjunctiva, anecteric sclerae, no TP congestion, and no A/N discharges
Neck: Supple, trachea midline, (-) lymphadenopathies
Chest: Symmetrical expansion, clear breath sounds
Heart: tachycardic, S1,S2 distinct with no murmurs
Abdomen: slightly globular, hypoactive bowel sounds (+) direct tenderness RLQ
Back: (+) KPS right
Genitourinary: Empty rectal vault, prostate not enlargement, (+) tenderness right pararectal vault
Extremities: No cyanosis, edema, clubbing
COURSE IN THE WARD
He was immediately started on IVF’s, infused 500mg of metronidazole IV and prepared for an emergency appendectomy. Operative finding
revealed a ruptured and highly inflamed appendix with purulent discharge. Appendectomy was done and the patient tolerated the procedure
fairly well. Two hours after surgery he developed difficulty of breathing with hypotension. Examination of the chest showed diffuse crackles
with occasional wheezing, ABG was done while patient was breathing oxygen at 4L/min by nasal canula revealed a pH 7.52, pO2: 54 mmhg,
pCO2 28 mmhg, HCO3: 22 meq/L, SaO2= 88%, his oxygen was increase to 6L/min by nasal canula and furosemide 40 mg was given by vein.
Cefipime 1 gm q8h was added to his antibiotic regimen, his dyspnea worsened and he became restless and cyanotic, a referral to pulmonary
service was made, a stat chest x rat showed patchy infiltrates at the lung quadrants with relative sparing of the costo-phrenic angles. A repeat
ABG showed further worsening in the patient’s oxygen tension and acid-base status: pH=7.36 pCO2= 38 pO2= 46 mmHg, HCO3 =16 meq/L and
SaO2 = 76%. He was then intubated and attached to a volume respirator. A 10 cm PEEP at 60% FiO2 keep his oxygen saturation above 90%.
On the next 4 days, he gradually improved with improvement if his lung infiltrates. His furosemide IV was reduced and he was then extubated
after a successful 3-day weaning on the 9th day of hospitalization. He was subsequently discharge a few days later.
II. PRIMARY IMPRESSION
DIAGNOSIS RULE IN RULE OUT
Severe ARDS HPI: Sought admission due to increasing RLQ pain accompanied with high grade fever and Cannot be ruled out
secondary to sepsis chills
Vital Signs: BP: 90/60 mmhg HR: 110/min RR: 24/min Temp: 39.2 C
P.E: Abdomen: slightly globular, hypoactive bowel sounds (+) direct tenderness RLQ
Course in the Ward:
HPI: (+) undergone emergency appendectomy
(+) operative findings: ruptured and highly inflamed appendix with purulent
discharge
P.E: (+) developed difficulty of breathing with hypotension 2 hour post-op
(+)chest showed diffuse crackles with occasional wheezing
(+) worsening of dyspnea
(+) restless and cyanotic
(-) cardiogenic evidence of pulmonary edema
Labs:
ABG: (+) initially develop respiratory alkalosis with decreasing SaO2
(+)PaO2/FiO2= 186 mm Hg
(+) worsening of O2 tension and acid-base status: combined respiratory and
metabolic acidosis with moderate hypotension
(+) PaO2/FiO2= 76mm Hg

Chest X-ray: patchy infiltrates at the lung quadrants with relative sparing of the costo-
phrenic angles
III. DIFFERENTIAL DIAGNOSES
DIAGNOSIS RULE IN RULE OUT
1. Aspiration Vital Signs: BP: 90/60 mmhg HR: 110/min RR: 24/min Temp: 39.2 C (+) competent airway protection
Pneumonia Course in the Ward: (-) evidence of large volume gastric
(chemical HPI: (+) undergone emergency appendectomy contents aspirated
Pneumonitis) (+) operative findings: ruptured and highly inflamed appendix with (-) evidence of vomiting or reflux of
purulent discharge gastric content during operation
P.E: (+) developed difficulty of breathing with hypotension 2 hour post-op (-) dullness to percussion over
(+)chest showed diffuse crackles with occasional wheezing consolidation
(+) worsening of dyspnea (-) pleural friction rub
(+) restless and cyanotic (-) cough with pink or frothy sputum
(-) cardiogenic evidence of pulmonary edema Chest-x ray:
Labs:  most common location of
ABG: (+) initially develop respiratory alkalosis with decreasing SaO2 aspiration is right lower lobe due
(+)PaO2/FiO2= 186 mm Hg to larger caliber and more
(+) worsening of O2 tension and acid-base status: combined respiratory vertical R main bronchus
and metabolic acidosis with moderate hypotension  volume loss in any lobar area
(+) PaO2/FiO2= 76mm Hg which may suggest obstruction
Chest X-ray: patchy infiltrates at the lung quadrants with relative sparing of the by aspirates
costo-phrenic angles
2. Acute Vital Signs: BP: 90/60 mmhg HR: 110/min RR: 24/min Temp: 39.2 C Onset is usually subacute, over days
interstitial Course in the Ward: to weeks
pneumonia HPI: (+) undergone emergency appendectomy
(+) operative findings: ruptured and highly inflamed appendix with P.E: (+) developed difficulty of
purulent discharge breathing with hypotension 2 hour
P.E: (+)diffuse crackles with occasional wheezing post-op
(+) worsening of dyspnea
(+) restless and cyanotic
Labs:
ABG: (+) initially develop respiratory alkalosis with decreasing SaO2
(+)PaO2/FiO2= 186 mm Hg
(+) worsening of O2 tension and acid-base status: combined respiratory
and metabolic
acidosis with moderate hypotension
(+) PaO2/FiO2= 76mm Hg
Chest X-ray: patchy infiltrates at the lung quadrants with relative sparing of the
costo-phrenic angles
3. Hypersensiti Vital Signs: BP: 90/60 mmhg HR: 110/min RR: 24/min Temp: 39.2 C (-) inhalation of an organic antigen
vity Course in the Ward:
pneumonitis P.E: (+)diffuse crackles with occasional wheezing (-) clinical history of an inhalational
(+) worsening of dyspnea allergen, usually of avian origin
(+) restless and cyanotic
(-) cardiogenic evidence of pulmonary edema
Labs:
ABG: (+) initially develop respiratory alkalosis with decreasing SaO2
(+)PaO2/FiO2= 186 mm Hg
(+) worsening of O2 tension and acid-base status: combined respiratory
and metabolic
acidosis with moderate hypotension
(+) PaO2/FiO2= 76mm Hg
Chest X-ray: patchy infiltrates at the lung quadrants with relative sparing of the
costo-phrenic angles
4. Acute ID: 56 year old male (-) history of cardiac disease
exacerbation of P and S Hx: smokes 3-5 sticks of cigarette/day for the last 40 year. (-) acute myocardial ischaemia or
CHF Vital Signs: BP: 90/60 mmhg HR: 110/min RR: 24/min Temp: 39.2 C infarction
Course in the Ward: (-) known low ejection fraction
HPI: (+) undergone emergency appendectomy suggests cardiogenic pulmonary
(+) operative findings: ruptured and highly inflamed appendix with edema
purulent discharge (-) murmurs on p.e.
P.E: (+) developed difficulty of breathing with hypotension 2 hour post-op (-) elevated neck veins on physical
(+)chest showed diffuse crackles with occasional wheezing examination
(+) worsening of dyspnea Chest X-ray:
(+) restless and cyanotic (+) relative sparing of the costo-
Labs: phrenic angles
ABG: (+) initially develop respiratory alkalosis with decreasing SaO2
(+)PaO2/FiO2= 186 mm Hg
(+) worsening of O2 tension and acid-base status: combined respiratory
and metabolicacidosis with moderate hypotension
(+) PaO2/FiO2= 76mm Hg
IV. RATIONAL LABORATORY & DIAGNOSTIC TESTS
PATIENT NORMAL
LAB. TEST INTERPRETATION/NECESSITY COST
RESULTS VALUES
CBC with Differentials: Complete Blood Count is done in order to assess the Php 220.00
Hemoglobin 12.0–15.8 g/dL stability and condition of the cells in the blood.
Hematocrit 35.4–44.4 % *in in case there may be an increase in WBC since
Total WBC 4000-9000 mm3 there is presence of infection
Segmenters Not provided 55-70%
Lymphocytes 20-30%
Eosinophil 0-6%
Monocyte 1-4%
Basophil 0-3%
Platelet count 165–415 × 109/L
Blood Glucose Test Amount of glucose (“sugar”, measured in mg/dL) in PHP 100
Random blood Glucose Not provided <140 your blood changes throughout the day and night.
*it is ordered as part of the management of Septic
shock
Kidney Function Test Creatinine to determine the degree of muscle Php 390.00
Creatinine Not provided 0.5-0.9 g/dl wasting and also to detect the glomerular filtration
rate (GFR). Uric acid is the final oxidation of purine
metabolism that is excreted in the urine. A buildup of
uric acid in the blood can be result of increase
production of the compound or decreased excretion
from the kidney
*in sepsis there is multi organ involvement and
assessment of the vital organ is necessary in order to
prevent complication and detect early involvement
of vital organs such as kidney and liver
Liver Function Test It is commonly measured clinically as a part of a Php 390.00
SGPT Not provided 7-41 U/L diagnostic evaluation of hepatocellular injury, to
determine liver health.
*in sepsis there is multi organ involvement and
assessment of the vital organ is necessary in order to
prevent complication and detect early involvement
of vital organs such as kidney and liver
Electrolytes Measurement of serum sodium, potassium is Php
Sodium Not provided 135-145 meq /L performed when the patient has symptoms of 290.00
Potassium 3.5-5.0 meq/L sodium and potassium and to assess hydration
status.
Urinalysis Urinalysis detects substances or cellular material in Php 60.00
Sp. Gravity Not provided 1.015-1.025 the urine associated with different metabolic and
pH 4.6-8.0 kidney disorders or any disorders in the urinary
Blood Negative system and assess for possible source of infection
Leukocytes 1-4/hpf and rule out UTI.
Red cells 2-4/hpf
Arterial Blood Gas ABGs are performed when information is needed Php
pH 7.52 7.36 7.35 – 7.45 regarding the acid-base status of the patient. The 1180
acid base balance of the body is controlled via 3
pCO2 28 46 35-45 mechanisms: the buffering system, the respiratory
mmHg mmHg and the renal system
pO2 54 38 mmHg 75-100mmHg 1st ABG: Respiratory alkalosis with moderate
mmHg hypoxemia. This may due to the excess carbon
monoxide exhaled brought about by impaired gas
HCO3 22 16 22-26meq/L exchange. PaO2/FiO2= 186 mm Hg
mEq/L mEq/L 2nd ABG: Compared to the initial ABG results above,
CO2 -- 20-29 meq/L pH and pCO2 have normalized which could mean an
BE -- -2/+2 impending respiratory failure if not managed
O2 saturation 88% 72% 95-100% immediately. PaO2/FiO2= 76mm Hg

IMAGING
Chest X-ray (PA) Patchy infiltrates at all lung quadrants with This reflects the leakage of fluid with a high protein PHP 240
relative sparing of the costophrenic angles content into the alveolar spaces because of alveolar
epithelial injury, or diffuse alveolar damage.
12 leads EKG ------- Ordered to rule out any cardiogenic cause of PHP 250
pulmonary edema
FINAL DIAGNOSIS:
Severe ARDS secondary to sepsis
PATHOPHYSIOLOGY
V. THERAPEUTIC MANAGEMENT
LIST OF PROBLEMS
1.Sepsis
2.Respiratory distress
3. Acid-base imbalance
ADVICE AND INFORMATION
1. Educate patient and family about the disease, the
risk factors, and the management for Sepsis and
ARDS as well as the possible sequelae.
2. Inform patient and family of the possible
complications which may result in the absence or
during the course of treatment.
3. Instruct patient to seek immediate consult if she
experiences signs and/or symptoms
complications.
4. Emphasize to the family, their importance as part of
the collaborative team in the management of the
patient.
5. Stress the importance of social and psychological
support during treatment and during the whole
duration of the disease process.
6. Encourage and emphasize the importance of
compliance to treatment regimen.
7. Inform the patient about the possible side effects of
the medications to be taken.
8. Teach the family or the watcher signs and
symptoms that may indicate worsening of the
disease.
9. Advise patient to stop smoking and avoid exposure
to secondary smoke.
10. Advise patient to maintain proper nutrition.
VI. PHARMACOLOGIC MANAGEMENT
Antibiotic
DRUG NAME EFFICACY
cefepime 4th generation
cephalosporin:has gram-
negative coverage, rapidly
penetrates gram negative cells
metronidazole Inhibit nucleic acid by
disrupting DNA and causing
strand breakage
Diuretics
Furosemide Loop diuretic; inhibit
reabsorption of sodium and
chloride ions at the proximal
and distal renal tubules and
loop of henle; by interfering
with chloride binding
cotransport system causes
increase in water, calcium. Mg,
Na and Cl
Inotropic Agent
Dopamine Endogenous catecholamine,
acting on both dopaminergic
and adrenergic neurons
THERAPEUTIC OBJECTIVES
1. Prevent the progression of shock
2. To normalize vital sign
3. Relieve respiratory distress and treat underlying cause
4. Minimize or prevent complication
5. Achieve normal acid-base balance
NON-PHARMACOLOGIC MANAGEMENT
1. Admit to ICU for monitoring of vital signs, ECG, intake and output,
sensorium, serial ABG, hct, electrolytes, blood glucose.
2. IVF: plain NSS with parenteral nutrion
3. Intubate patient and attach to mechanical ventilator with the following
initial settings:
of
 Assist-control mode is used initially with a tidal volume 6 mL/kg
ideal body weight, respiratory rate 25/min, flow rate 60 L/min,
FIO21.0, and PEEP 15 cm H2O.
 Once O2 saturation is > 90%, FIO2 is decreased.
 Then, PEEP is decreased in 2.5-cm H2O increments as tolerated to
find the least PEEP associated with an arterial O2 saturation of 90%
on an FIO2 of ≤ 0.6.
 The respiratory rate is increased up to 35/min to achieve a pH
of > 7.15, or until the expiratory flow tracing shows end-expiratory
flow.
4. Diet: NPO
5. Chest x-ray
6. Prone positioning
7. Treat underlying cause
SAFETY SUITABILITY
Rash, N and V, diarrhea, Treatment for sepsis and intraabdominal
pruritus, headache, infections; use in combination with
eosinophilia and fever metronidazole
Nausea, vomiting, dark urine, Treatment for anaerobic bacterial infection
diarrhea, dizziness and
headache
Hyperuricemia, hypokalemia, Treatment for acute pulmonary edema
anaphylaxis, anemia, anorexia
and diarrhea
Ventricular arrythmmia, atrial Treatment of hypotension, low cardiac output,
fibrillation, ectopic beats and poor perfusion of vital organs; increase mean
tachycardia arterial pressure in septic shock
VII. MONITORING AND FOLLOW-UP
1. Have the patient come back after 1 week
2. Monitor vital signs and blood glucose
3. Diet and lifestyle modification.
4. Lab tests: FBS, spirometry, CBC and chest x-ray
5. Monitor for response to treatment. Instruct patient to report to health care provider for any adverse reactions to treatment or
worsening of condition.
6. Monitor adherence to therapeutic regimen.
7. Monitor patients with persistent symptoms and/or exacerbations despite treatment.
8. Monitor for the affectivity of the prescribed treatment
9. Refer accordingly

Brunton, L., et al. (2012). Goodman and Gilman’s Pharmacological Basis of Therapeutics, 12th Ed. The McGraw-Hill
Companies, Inc.: USA.
Fauci, A., et al. (2012). Harrison’s Principles of Internal Medicine, 18th Ed. The McGraw-Hill Companies, Inc.: USA.
Katzung, B. (2007). Basic and Clinical Pharmacology, 10th Ed. The McGraw-Hill Companies, Inc.: USA.
Kumar, R., et al. (2010). Robbins and Cotran Pathophysiologic Basis of Disease, 8th Ed. Saunders Elsevier: Philadelphia, USA.
Ong, W. T., et al. (2013). Expanded Medicine Blue Book, 5th Ed. CachoHermanos, Inc.: Mandaluyong City, Philippines.

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PHILIP JAY D BRAGA, M D

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PHILIP JAY D BRAGA, M D PHILIP JAY D BRAGA, M D

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