Motality case 경희의료원 소화기내과 General weakness 를 주소로 내원한 71 세 남자환자 R1. 박은지 / pf. 심재준
주호소 General weakness onset) 당일오전 현병력 71/M DM, HTN, A-LC (MELD 13.86, Child B(8)), HCC s/p TACE #15 ( ~ ) 로 ~ conservative management 후 퇴원한 환 자로 다음주 재입원예정이었으나 내일당일 오전 general weakness, sputum, abdominal pain 악화되어 외래경유 입원 성 명 : 김 O 규 성 별 : M / 71 병록번호 :
과거력 DM(+) : 1993 년 진단, novomix unit, 본원 IE f/u HTN(+) : 1993 년진단, 본원 IE f/u Op Hx (+) Appendectomy : 40 년전 Post. sectinonectomy c Rt adrenectomy c cholecystectomy : 2004 Drug Hx 본원 IG med 만 복용 > Rifaximin 400mg bid, Cilostazol 100mg qd, Ranitidine 150mg bid, Mecobalamin 500ug tid, Mosapride 5mg bid, Megace 1P qd, Norzyme 1T tid, Paramacet 1T prn, Synthitoxin 1T qd ** ~ : Nexavar (sorafenib) 200mg bid 성 명 : 김 O 규 성 별 : M / 71 병록번호 :
04’-0910’-1111’-0511’-1212’-0212’-0512’-0912’-1213’-0313’-0613’-099/3~9/14 OP ( 본원 GS) Rt post sectinectomy cholecystectomy Rt adrenalectomy 과거력 TACE #6 TACE #7 TACE #8 TACE #9 TACE #10 TACE #11 TACE #12 TACE #13 TACE #14 TACE # ~ TACE # Lv CT Agg. of multinodular HCCs at both lobes 8/13~9/2 Nexavar (sorafenib) MELD ’-1113’-0313’-0513’-0713’-09 AFP PIVKA-II
계통문진 1. General Fever(-) Chill(-) Sweating(-) Edema(-) Poor oral intake(+), General weakness (+) 2. Skin Rash(-) Itching(-) Pigmentation(-) Jaundice(-) 3. Head & Neck Headache(-) Pain(-) Stiffness(-) Mass(-) Sore Throat(-) 4. Respiratory Cough(+), Sputum(+), Dyspnea(-) 5. Cardiac Chest Pain(-) Palpitations(-) 6. Gastrointestinal Anorexia(-) Nausea(-) Vomiting(-) Diarrhea(-) Constipation(-) Abdominal pain (+) 7.Genitourinary Flank pain(-) Dysuria(-) Urgency(-) Incontinence(-) Tenesmus(-) 8. Musculoskeletal Fainting(-) Dizziness(-) Sensory loss(-) Motor weakness(-) Tremor(-)
신체검진 키 160cm – 체중 62 kg – BMI 24.2 Vital Sign 140/80mmHg - 105/min - 20/min – 36.8 ℃ 1. General Alert consciousness Acute-ill looking appearance 2. E/ENT Isocoric pupil c PLR(++/++) Pinkish conjunctiva/whitish sclera Pharyngeal injection(-)PTH(+/+) 3. Chest Symmetric lung expansion Clear breathing sound without rale, wheezing Regular heart beat without murmur 5. Abdomen Soft/ flat abdomen Bowel sound: normoactive Tenderness(+) : RUQRebound tenderness(-) Palpable mass(-) Central obesity (-) 6. Back & extremities CVA Td(-/-)Pretibial pitting edema(-/-) 7. Neurology Motor Sensory V / V 100 / 100
Initial Lab findings ( ) CBC 280(/uL) – 13.2 (g/dL) – 41(%) – (/uL) (seg 12.7 (%)) aPTT/PT/PT INR 34.0(sec)/ 14.1(sec)/ 1.12 Chemistry BUN/ Cr41/0.9 (mg/dL) Prot/ Alb6.3/3.0 (g/dL) Na /K /Cl138/4.6/100 (mEq/L) AST/ALT105/41 (IU/L) Ca/ P/ Mg8.7/3.8/2.5 (mg/dL) ALP/rGT 165/570 (IU/L) Glucose97 (mg/dL) TB/DB 6.67/4.75 CRP13.15 (mg/dL) Urine analysis pH 5.0 SG Glucose-/ uribilirubin+- / Ketone-/ protein – RBC / WBC2~4 / 0~1 Procalcitonin AFP ANC 35.56
Initial Chest Xray ( )
Initial Abdomen Xray ( ) SE
Initial EKG ( )
Impression #1. r/o hepatoma rupture #2. Neutropenia #3. HCC s/p TACE #15 #4. A-LC (MELD 13.86, Child B(8)) #5. Known DM #6. Known HTN
Liver CT ( ) PACS 영상 비교하여 both hepatic lobes 의 mass 는 크기와 갯수 모두 큰 변화 없어 보이며 left lateral segment 에 제일큰 HCC 가 있음 Underlying liver cirrhosis 와 splenomegaly 도 큰 변화 없어 보임 No significant interval change of multinodular HCCs at both lobes No significant interval change of lipidoloized lesions in both lobes of liver
Clinical course ( ) (14:00~) ANC 35 → 역격리, Glasin (filgrastim) Fever 38.0 → Antibiotics start (pip/tazo) Pain control (Morphine mixed fluid iv continous) Check V/S q1hr (21:30) Chest discomfort(+)
EKG ( , 21:45)
Clinical course ( ) (05:00) V/S 110/ 보호자 ( 배우자 ) Keep 계속 깨어있는 상태로 환자에게 계속 말 걸었다고 함 환자 대답하며 보호자 질문에 반응 있었다고 함 (05:45) 환자 대답 없고 반응 없어 보호자 간호사실에 알림 No pulsation on carotid & femoral artery No pupil reflex c full dilatation No self respiration (05:55) CPR 방송 후 Cardiac compression 하며 치료실로 이동 EKG monitoring : flat 보호자 ( 아들 ) 연락 → CPR 지속 및 ICU 전동 동의 Inotropics (LEVO/DOPA) full Intubation & ambu-bagging (06:25) ICU 전동, CPR 지속 (06:35) 보호자 ( 아들 ) 병원 도착 후 CPR 중단 요구, DNR paper 작성후 CPR 중단
CPR lab ( ) CBC 2430(/uL) – 11.1 (g/dL) – 35.6(%) – (/uL) (seg 6 (%)) aPTT/PT/PT INR 42.9(sec)/ 19.2(sec)/ 1.68 Chemistry TnI 0.06 CK-MB 4.4 → CPR Lab 결과보고 전 ICU 로 전동되었으며 Sample clot 으로 검사실에서 재검 연락 왔으나 사망선고 후로 재검 못함 ABGA pH – pCO – pO – HCO – sO2 15.6
#1. r/o Cardiac arrest #2. r/o Hepatoma rupture #3. r/o Septic shock Causes
Problem Lists Neutropenia Para-neoplastic? Sepsis-induced? Drug-related? Fever Sepsis? Cancer fever? M/71 Alcoholic LC, Recurrent HCCs, repeated TACE sorafenib DM Sudden death Sudden cardiac & respiratory arrest Sudden death Sudden cardiac & respiratory arrest Drugs Sorafenib hold G-CSF Morphine Antibiotics Malignancy Recurrent, advanced HCC Tumor rupture? Vascular invasion? Brain metastasis? Cardiopulmonary dis. AMI? Pulmonary embolism?