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Case Presentation 2006/09/01
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Basic Information Name: 楊x婷 Chart NO: 0476xxxx
11-year-2-month-old girl Admission date: 2006/08/28 Bed NO: 4P106
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Chief Complaint Progressive tachypnea for 10+ days
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Present Illness A patient of 3~4 days prior to 8/19
Corrected TGA, VSD, ASD, pulmonary atresia, situs inversus s/p Rastelli operation in 92/2 Hypoxic encephalopathy 3~4 days prior to 8/19 Spiking fever up to 39C, cough, irritable, poor intake 8/19 Chi-Mei hospital CXR: RLL pneumonia Lab: WBC 18900, Seg 83%, CRP 213, Hb 6.4, MCV 62.8, RBC 3.36 PLT 589k Admission Antibiotic with Augmentin
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Admission Course in CMH
8/23~8/25 PICU 8/23: progressive tachypnea PICU Hb 5.4 g/dL blood transfusion with pRBC 8/25: tachypnea improved general ward 8/25~ Still spiking fever up to 39C Antibiotic Vancomycin + Ceftriaxone Poor appetite, easily choking due to tachypnea, progressive tachypnea 8/28 Antibiotic Vancomycin + Ceftazidime Family asked for transferring to our hospital
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8/ /26
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8/28
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Past History Birth history: Feeding: soft diet
G5P3, NSD, GA 39 weeks, BBW 3650gm DOIC (-), PROM (-), APGAR 9 9 Feeding: soft diet Vaccination: on schedule Growth and Development BW 22Kg (<3th%), BL can not check Development milestone: delay Family history Older brother: cough
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Physical examination Conscious: alert
Vital sign: T/P/R 37.4/104/40, BP 106/76 HEENT: conjunctive: not anemic sclera: not icteric throat: not injected eardrum: not injected Chest: symmetric expansion, subcostal retraction (+) B.S.: bilateral coarse, crackles, rhonchi H.S.: RHB, systolic murmur Gr III/VI Abdomen: soft, no tenderness, normative bowel sound Liver/Spleen: impalpable/impalpable Extremities: freely movable, pitting edema at bilateral forearm Skin: tugor fine, rash at perineum
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Lab Data on 8/28 CBC WBC Band Seg Mono Lym Hb RBC MCV 16700 9 84 1 6
7.6 3.5 70.1 PLT PT APTT Fib FDP 540k 13.10/12.0 32.90/27.20 460 >1050 BCS BUN Cre GOT GPT Bil T/D LDH Alb T.P. 7 0.5 31 21 0.4/0 304 2.7 7.2 CRP 145.1
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Gas pH PCO2 PO2 HCO3 BE O2 supply 15:56 V 7.308 58.8 26.9 28.8 2.5 Simple mask 18:37 C 7.460 43.9 47.2 30.5 6.7
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CXR in NCKUH on 8/28
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Chest echo Right pleural effusion Thoracocentesis
100ml pus-like effusion was drained
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GPC in group, GPC in chain, GNB
Pleural effusion Empyema Gram stain GPC in group, GPC in chain, GNB Appearance Pus-like Seg 100% pH 6.509 LDH 46785 (serum 304) T.P. -
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Tentative Diagnosis Bilateral lung pneumonia with empyema
Microcytic anemia R/O infection-related R/O iron deficiency anemia R/O hemolytic uremic syndrome Corrected TGA, ASD, VSD, pulmonary atresia, situs inversus s/p Rastelli operation Hypoxic encephalopathy
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Plan Antibiotics with Vancomycin + Ceftriaxone Aggressive chest care
Chest tube insertion Check urine pneumococcus Ag Pursue all culture results (blood, pleural effusion, sputum) Blood transfusion with pRBC Cardiac echo
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Clinical Course
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8/29 Urokinase for complicated empyema, but…
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SaO2 under non-rebreathing mask: 70~80%
Re-on chest tube Normal saline leak to subcutaneous tissue Hold urokinase Keep chest tube for drainage Microgas: pH 7.405, PCO2 58.8, HCO3 35.9 SaO2 under non-rebreathing mask: 70~80% impending respiratory failure endotracheal tube intubation Antibiotics: Vancomycin + Cefepime
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8/30 Chest echo: much pleural effusion at right side
Poor drainage function of chest tube Consult chest surgeon for re-on Chest surgeon Re-on chest tube may injure the lung parenchyma tissue Suggest to arrange chest CT
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Chest CT on 8/30
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Decortication on 8/31
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8/31
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Lab data CBC WBC Band Seg Mono Lym Hb MCV PLT 8/29 16700 9 84 1 6 7.6
70.1 540k 8/30 9600 15 71 2 10 9.2 74.2 347k 8/31 11200 19 65 7 11.5 77.7 339k BCS CRP 145.1 82.6 65.3 23.6
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Culture result 8/28 8/31 Blood: negative Sputum: yeast-like, moderate
Empyema: negative Urine pneumococcus Ag: negative 8/31 Empyema: pending
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Management of pleural effusion
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Thanks for your attention !
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Evaluation for anemia Reticulocyte 3.3% , RDW 29.4%
Haptoglobin 222 Iron 26 TIBC 158 Ferritin Transferin 144 T-antigen: negative
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