G E N E R A L D ATA

38 year old
Male, from Cavite,
D I FnoF known
I C U LT Y
O F comorbidities
BREATHING
 H I S T O R Y O F P R E S E N T
I L L N E S S

15 MOS. PTA

9 MOS. PTA

5 MOS. PTA

4 MOS. PTA
• Inc. H I S T O R
freq. of coughY • OCough
F P+ R E S phlegm
whitish E N T
•
I L L assoc.
Fever and back pain N E S with
S night sweats
• No hemoptysis • No hemoptysis or fever
• X-ray: Pleural effusion • Px self-medicated with
• Treated as Pneumonia Carbocisteine, did not relieve
15 MOS. PTA
• Given antibiotics, was compliant
symptoms
9 MOS. PTA
• Relief of fever and dec. freq. of
cough • Recurrence of fever 5 MOS. PTA
• Persistent productive cough, whitish
4•MOS. PTAdone
CT scan phlegm, bloody streaks
• Biopsy requested Weight loss (20%)
•

• Chest Ultrasound: PULMONARY MASS

• Given expectorants & antibiotics
 H I S T O R Y O F P R E S E N T
I L L N E S S

3 MOS. PTA

2 MOS. PTA

1.5 MOS. PTA

1 MONTH PTA
 H I S T O R Y O F P R E S E N T
I L L N E S S
• Px was on regular follow-up
• Started on anti-tuberculosis
• FNAB was done:

& steroids BENIGN3lesion

MOS. PTA
•Dec. severity
2 MOS. PTA of cough

• Still had cough assoc. with Chest pain & Dyspnea1.5 MOS. PTA
• Admitted for 10 days
1 MONTH PTA • Improvement of symptoms
• O2 support given
• Steroids were tapered
• CT-guided lung mass biopsy was requested
• Mild improvement of dyspnea
• Patient was discharged on O2 support at home
H I S T O R Y O F P R E S E N T
I L L N E S S

• Experienced SEVERE DYSPNEA

• THREE HOURS PTA
Prompted consult and subsequent
admission
PA S T M E D I C A L
H I S T O R Y
 PA S T M E D I C A L
H I S T O R Y

No history of hypertension

No history of diabetes mellitus

No history of bronchial asthma or allergies

FA M I LY H I S T O R Y
 FA M I LY H I S T O R Y

Pulmonary Tuberculosis
Mother

Pneumonia
Sibling
P E R S O N A L & S O C I A L
H I S T O R Y
 P E R S O N A L & S O C I A L
H I S T O R Y
Unemployed, former Factory worker,
regularly exposed to paint thinner

4 pack-year smoker

Regular alcohol drinker (4x a week) for 23 years

Had multiple sexual partners

Has 4 children with current live-in partner

R E V I E W O F S Y S T E M S
R E V I E W O F S Y S T E M S

Weakness Cough

Abdominal pain

Dysuria

Bowel
Movement
Changes
P H Y S I C A L E X A M

Drowsy

Cardiorespiratory
distress
 P H Y S I C A L E X A M
Constitutional

BLOOD
PRESSURE 130/90 mmHg

HEART
RATE 140 bpm

RESPIRATORY
RATE 32 cpm

BODY
TEMP. 37.3C

O2 SAT. 92%
 P •HUnequal
Y S chest
I C expansion
A L E X A M
• Chest lag on the Right
• Anicteric sclerae
• Dullness on percussion on R lung field

• Pale palpebral conjunctivae

• Dec. breath sounds on the R Mid - Upper lung field
• No breath sounds over the R lower lung field
• No cervical lymphadenopathy
• Clear vesicular breath sounds on the left lung
• Marked neck• vein engorgement
No wheezes, crackles, rhonchi noted.

• Full & equal pulses

• Distinct heart sounds
• Pink nail beds
• Elevated heart rate
• No cyanosis
Regular rhythm
•
• No edema • Flat abdomen
• No murmur
• No clubbing • Normoactive bowel sounds
• No S3/S4
• No masses or tenderness
D I A G N O S T I C S
 D I A G N O S T I C S
CBC
Result Int.
Hgb
N = 120 - 180 g/L
169 N
Hct
N = 0.370 - 0.540
0.49 N
WBC
N = 4.4 - 11
12
RBC
N = 4.0 - 6.0
5.49 N
MCV
N = 80.0 - 100.0 fL
87 N
 D I A G N O S T I C S

CBC

Result Int.

MCH
N = 12.0 - 31.0 pg
29.4 N

MCHC
N = 320 - 360 g/L
338 N

Platelet
N = 150 - 450
360 N
 D I A G N O S T I C S
CBC
Result Int.
Lymphocytes
N = 0.200 - 0.500
0.129
Neutrophils
N = 0.500 - 0.700
0.767
Monocytes
N = 0.020 - 0.090
0.045 N
Eosinophils
N = 0.000 - 0.060
0.000 N
Basophils
N = 0.000 - 0.020
0.001 N
 D I A G N O S T I C S
CHEM
1st HD 2nd HD Int.
Crea
N = 53 - 115 umol/L
69 N
Na
N = 136 - 145 mmol/L
118 120
K
N = 3.50 - 5.10 mmol/L
2.0
Cl
N = 98 - 107 mmol/L
76
Albumin
N = 38 - 51 g/L
36
Ca
N = 2.12 - 2.75 mmol/L
2.22 N
 D I A G N O S T I C S
ABG
1st HD 3rd HD 4th HD
pH
N = 7.35 - 7.45
7.557 7.312 7.308
PCO2
N = 35 - 45
23.2 51.2 35
PO2 58 45 57.2
HCO3
N = 22 - 28
20.5 26.3 21
O2Sat 93.8% 75.2% 89.3%
Partially Uncompensated Partially
compensated respiratory compensated
respiratory alkalosis acidosis metabolic acidosis
 D I A G N O S T I C S
SPUTUM:

PMN <25
Squamous Epithelial cells >25
D I A G N O S T I C S
ECG:

Sinus tachycardia
Normal axis
 R E V I E W O F S Y S T E M S

C O U R S E
I N
T H E
WA R D
 C O U R S E I N T H E W A R D

ADMISSION
Admitted under Gen. Medicine Service
Put under NPO
Hooked to IVF: PNSS 1L x 12 hrs.
Requested CBC, Blood chem, Sputum
GS/CS, Chest CT
Tx: Anti-TB meds, Vit. B complex,
Ipatropium + Salbutamol nebulization
Vital signs monitored hourly.
 C O U R S E I N T H E W A R D

1st HOSPITAL DAY

Patient awake
Persistent cough & dyspnea
Tachycardic & Tachypneic
O2 Sat: 96%
Dec. breath sounds in the mid & basal
lung fields of both lungs, marked on R
lung.
Plan to repeat Chest CT + Biopsy
IV potassium correction started
Medications & O2 support continued
 C O U R S E I N T H E W A R D

2nd HOSPITAL DAY

Persistence of cough with whitish
phlegm
Still tachypneic & dyspneic
Breath sounds still decreased
For CT-guided aspiration of
pulmonary mass
Medications continued
 C O U R S E I N T H E W A R D

3rd HOSPITAL DAY

Referred for dyspnea & cyanosis
Auscultation: Tight air entry
O2 Sat: 83%
Intubated
Copious yellowish blood-tinged
secretions noted
 C O U R S E I N T H E W A R D

3rd HOSPITAL DAY

Started on Piperacillin-Tazobactam &
Azithromycin
One episode of Anisocoria
Positive Doll’s Eye
Given Midazolam 5mg
Family did not consent to 2nd lung
biopsy
 C O U R S E I N T H E W A R D

4th HOSPITAL DAY

Seen by Pulmonology service
Advised shifting to Meropenem and
continue other meds.
 C O U R S E I N T H E W A R D

5th HOSPITAL DAY

Referred to Medical ICU
Px self-extubated
Attending physicians
re-intubated him
 C O U R S E I N T H E W A R D

6th - 7th HOSPITAL DAY

Persistence of dyspnea & hypoxia
Patient expired
P E R T I N E N T D ATA
38 Y/O
Male
Mother previously treated for
PTB
Sibling died of Pneumonia
Former factory worker,
regularly exposed to paint
thinners
4 pack-year smoker
Multiple sexual partners
P E R T I N E N T D ATA

Back pain
Night sweats
Fever
Productive cough (whitish
phlegm + blood streaks)
20% weight loss
Chest pain

Severe dyspnea
 D I F F E R E N T I A L D I A G N O S I S

PULMONARY MASS

Infection Neoplasm

Lung Pulmonary Lung Cancer

Abscess Tuberculosis
(Tuberculoma)
 INFECTION
LUNG ABSCESS
Risk factors:
Possible Immunosuppression:
— Alcoholism (4x a week for 23 years)
— Multiple sexual partners - may have contracted HIV)
Pneumonia
Evidence of Lung Abscess:
Dyspnea Fatigue
Fever Abscess from aspiration of 
infective material - more
Night sweats
common on R side and single
Productive cough
Copious, foul smelling sputum
Purulent, blood streaked sputum X-ray: pleural effusion, no
Weight loss (20%) distinct round shape, no air-
Chest pain fluid level
 INFECTION
PULMONARY TUBERCULOSIS
(TUBERCULOMA)
Risk factors:
Exposure to PTB (mother prev. treated for PTB)
4 pack-year smoker
Former factory worker (confined spaces, poor ventilation)
Multiple sexual partners (to consider immunosuppression)

Evidence of Pulmonary Tuberculosis:

Dyspnea Weight loss (20%)
Fever Weakness
Night sweats Chest pain
Productive cough Back pain
Blood streaked sputum Pulmonary mass
 NEOPLASM
LUNG CANCER
Risk factors:
Closely related to smoking (4 pack-year smoker)
Former factory worker (regularly exposed to paint thinners)

Evidence of Lung Cancer:

Chronic cough (productive + whitish phlegm & blood streaks)
Difficulty of breathing
Chest pain
Back pain
Unexplained weight loss (20%)
Weakness
Pulmonary mass
 NEOPLASM
LUNG CANCER
Evidence of Lung cancer:
Ages 40 & 70 y/o; peak evidence 50s or 60s
Nearly linear correlation between the frequency of lung
cancer and pack-years of cigarette smoking
Relationship of exposure to paint thinners to Lung CA is
not well-established
MAIN CLINICAL DIAGNOSIS
 M A I N C L I N I C A L D I A G N O S I S

PULMONARY TUBERCULOSIS
(Tuberculoma)
with
Recurrent Pneumonia
PATHOPHYSIOLOGY
 38 y/o, Male, former factory worker

Possible Multiple sexual

Immunosuppression partners,
Recurrent
Mother History of PTB Pneumonia

4 pack-year smoker

PULMONARY TUBERCULOSIS WEAKNESS

(Tuberculoma)
CHEST PAIN
Destruction & BACK PAIN
Airway Compression structural re-modelling
of lung vasculature WEIGHT LOSS
COUGH DYSPNEA
HEMOPTYSIS NIGHT SWEATS

SVC compression FEVER

Atelectasis NECK VEIN
R side lag, Unequal chest expansion ENGORGEMENT
Dec. breath sounds, Dullness

Respiratory Compromise
 Respiratory Compromise
Decreasing O2 Sat.
Cyanosis
Tight air entry

Persistent Dyspnea & Hypoxia

RESPIRATORY FAILURE

DEATH
Cause of Death
 C A U S E O F D E AT H

UNDERLYING CAUSE
Pulmonary Tuberculosis
(Tuberculoma)

ANTECEDENT CAUSE
Atelectasis

IMMEDIATE CAUSE
Respiratory Failure