86yo Male Weakness Post Pneumonia ICU

C L E R K S H I P
C A S E C O N F E R E N C E O F I N T E R N A L M E D I C I N E
CHIA-CHING, CHEN
KFSYSCC, 2017/01/02 13:30

PART01
Patient Profile, Chief Complaint
History of Present Illness
PART02
Past Medical History, Family and Personal History,
Review of Systems, Physical Examination
PART03
Assessment
Plan
PART04
Mini-Topic
CONTENTS
M R . R

ABOUT HIM
1 A 86 year-old man, with a history of disease-free prostate and colon
cancer and coronary artery disease s/p stent placement, who presents
with a chief complaint of 18 days progressive general weakness and
deconditioning ever since 2 weeks intensive care unit management for
pneumonia with septic shock and acute respiratory failure
M R . R ,
M R . R , H P I

Mr. R has a history of prostate and colon cancer under disease free condition with episodic adhesive ileus s/
p conservative treatment and coronary artery disease s/p PTCA and DES placement 7 months ago, now
with Clopidogrel only due to episode of UGI bleeding.
He was in his usual state of health until 18 days prior to admission to KFSYSCC when he was sent to SCMH
ICU for management of the acute onset of E-Coli related pneumonia with septic shock and acute respiratory
failure, s/p intubation, vasopressor and intensive care. Extubation was succeeded 5 days prior to admission
and he was transferred to SCMH general ward 3 days prior to admission.
During and after 2 weeks stay in the ICU, he gradually developed insomnia, persistent diarrhea, weight loss
and worsening general deconditioning. Furthermore, he has lost 10 kg sine ICU stay.
I S T O R Y O F P R E S E N T I L L N E S S
H M R . R , H P I

H P I M A N A G E M E N T
B P : 8 5 / 4 3 ; T P : 3 9 [ S T I N ]  
S E M I - C O M A
M R . R , H P I

H P I M A N A G E M E N T
M R . R , H P I

12/03: LOBAR CONSOLIDATION OVER RUL
CXR A-P: 12/03 & 12/16
Hello friends this is a
simple and easy to
modify the slide which
is a fashion trend of
the template Glad you
chose him I wish you a
happy life
CHANGEABLE
12/16: CHEST CONDITION IMPROVED, 
INCREASED LUNG MARKING AT RIGHT LUNG AND LEFT LOWER LUNG

2
Past Medical History, Family and Personal History, Review of Systems, Physical Examination
P A R T
CASE CONFERENCE 2017/01/02
M R . R

MEDICAL HISTORY
PAST
Surgical, Medical History and Medication
M R . R P M H

？H I S T O R Y
1999, Anal fistula operation
2000, Anterior resection for colon cancer; Bilateral cataract surgery
2005, Radical retropubic prostatectomy
2010, Bilateral total knee arthroplasty with septic arthritis; HIVD surgery;
2016, Percutaneous transluminal coronary angioplasty with drug-eluting
stents x 4
SURGICAL
W I T H O U T A D V E R S E E F F E C T O F A N E S T H E S I A O R B L O O D T R A N S F U S I O N
M R . R P M H

？H I S T O R Y
M R . R P M H
MEDICAL

Family members suffering from cancer -
Elder sister - Lung cancer
Elder brother - Gastric cancer
Younger brother and sister - Colon cancer
6 healthy sons
HISTORY
FAMILY
No common disease runs in his family
M R . R FA M I LY

Mr. R is a quite healthy widowed retired farmer
still brewing wine by himself. He could perform
ADL and IADL well. He lives alone only with a
foreign worker in Nanto, gathering with his family
during vacation and weekend; he hangs out with
his old friends tasting delicacies sometimes. His
descendants have fantastic relationship with him
though they all live in Northern Taiwan.
HISTORY
PERSONAL
‣ Alcohol: self-made rice wine 500mL/day
‣ Betel nuts: for 50 years, quit for 20 years
‣ Cigarette: for 50 years, quit for 20 years
‣ Caffeine: one cup everyday
‣ No TOCC and pet M R . R P E R S O N A L

REVIEW
General - Body weight loss 10 kg within 18 days, (+)Fatigue 
HEENT - (-)Headache, (-)Rhinorrhea, (-) Nasal Congestion, (+)Dry mouth, (-)Sore throat 
Cardiovascular - (-)Chest pain, (-)Dyspnea 
Respiratory - (+)Cough, (+)Whitish sputum 
Gastrointestinal - (+)Abdominal pain before evacuation, (+)Yellow-brown diarrhea 
Musculoskeletal - (+)Weakness
OF SYSTEMS ,
M R . R R O S

A
General Appearance  
A 86 year-old cachexia man with tenting
skin lying at the bed and appears slightly
elder his/her age. He was in good hygiene,
good attitude and without and
cardiopulmonary distress
B
Vital Signs 
T/P/R: 36.7C / 94 bpm / 24/min, BP: 110/56 mmHg 
BW: 51.8kg
CMental Status 
Alert and oriented to time/place/people
DChest 
Mild dyspnea with N/C 
Breath sounds: rhonchus at right lung field 
Respiratory weakness, accessory
respiration
PHYSICAL EXAMINATION
M R . R P E

E
Abdomen  
Inspection: scar 
Auscultation: hypoactive bowel sound 
Palpation: LUQ tenderness (nonspecific)
F
Neurology 
Muscle Power: 1+ - 2- in upper and lower extremities 
Sensation: Mostly Intact
G
Hemogram 
HGB 12.1 g/dl, HCT 35.9%, PLT 276,000/ul 
WBC 13,790/ul, BAND 4.0%, SEG 54.0%, Atypical Lymph 6.0 %
H
BCS 
Glucose 99 mg/dl 
BUN 24.9 mg/dl, Creatinine 0.65 mg/dl 
Total protein 5.56 g/dl, Albumin 3.68 g/dl,
Globulin 1.9 g/dl; AST 22 U/L, ALT 21 U/L 
Na 134 mmol/L, K 4.6 mmol/L, Ca 8.3 mmol/L
PHYSICAL EXAMINATION
M R . R P E

Stool, Urine Exam
BLOOD CELL DETECTED
They are likely due to tear near anus and folley trauma
Pathogen
SPUTUM, STOOL
Sputum - Light amount of Klebsiella pneumonia ssp
Stool - CDI (-)
M R . R P E

12/21: SOME ILL-DEFINED INFILTRATION AT RIGHT LUNG
BUT NO OBVIOUS PLEURAL EFFUSION
CXR A-P: 12/21
Hello friends this is a
simple and easy to
modify the slide which
is a fashion trend of
the template Glad you
chose him I wish you a
happy life
CHANGEABLE
12/16: CHEST CONDITION IMPROVED, 
INCREASED LUNG MARKING AT RIGHT LUNG AND LEFT LOWER LUNG
M R . R P E

NO ILEUS
KUB: 12/21
KUB M R . R P E

HEMOGLOBIN LEVEL (G/DL, N: 13.5-17.5)
M R . R B A S E L I N E

GLUCOSE LEVEL (MG/DL, N: 71-126)

POTASSIUM LEVEL (MMOL/L, N: 3.7-5.3)

SODIUM LEVEL (MMOL/L, N: 135-148)

CALCIUM LEVEL (MMOL/L, N: 8.6-10.2)

WBC LEVEL (MMOL/L, N: 3,600-10,000)

✴ > 10y - Colon and Prostate cancer s/p operation > 10 years ago, with episodic
adhesive ileus s/p conservative treatment (last: 2m ago)
✴ 7m - CAD s/p PTCA with DES x4 with plavix only
✴ 18d - E. coli related right upper lung pneumonia with respiratory failure and
septic shock s/p intubation, IV resuscitation, vasopressor, sedation, antibiotics/
antifungal and ICU care
✴ 5d - Extubation
✴ 4d - Transfer to general ward, with Glucocorticoid and sedation
✴ Admission - Significant cachexia with mild respiratory distress on N/C; Poor
nutrition with NG diet developing diarrhea, CXR - no obvious pleural effusion,
chronic anemia; Weight loss ~ 10 kg
8 6 Y / O M A L E
BRIEF
S U M M A R Y

P A R T
3
A S S E S S M E N T
P L A N
M R . R

PATIENT’S MAJOR PRESENTING PROBLEM IS
T
The differential diagnosis includes…
I M PA I R M E N T I N P H Y S I C A L F U N C T I O N
HE
M R . R

M R . R D / D
D I F F E R E N T I A L
D I A G N O S I S
S U S P E C T E D

ASSESSMENT
Post-critical illness weakness post E.coli related
pneumonia with RF and septic shock s/p 2 weeks
treatment course of antibiotics and ETT
Altered bowel movement: Loose to watery diarrhea
Potential UGI tract bleeding
Infection control
M R . R A & P

METHOD 02METHOD 01
Nutrition Build-Up: 
Dietitian consultation, 1200 Kcal/day.
Resuming oral feeding is the goal
METHOD 03 GOAL
Rehabilitation to restore
performance: 
Physical therapy for rehabilitation
program arrangement - therapeutic
exercise, strengthening treatment,
endurance / posture / balance /
cardiopulmonary / ambulation training,
respiratory function included
Nursing Home Care Education: 
Family discussion regarding assistant
device at home and life modification
Short-term: shortened bed-ridden
interval, actively engaging simple
movement such as turing body over or
position transfer from supine to sitting 
Mid to Long-term: Partial ADL and
IADL independency under mild
assistance
POST-CRITICAL ILLNESS WEAKNESS
M R . R A & P

METHOD 02METHOD 01
NG Diet Modification: 
NG feeding with pump to prevent
bowel overly stimulation and further
malabsorption
METHOD 03 METHOD 04
Diet Formula Adaption: 
Isotonic complete formula -> Clear-
liquid fat-free formula -> Elemental
feeding diet
Medication: 
K.B.T to improve bowel
microenvironment, Loperamide to
alleviate diarrhea symptom
Digestants: 
Shin Biofermin
PERSISTENT DIARRHEA
M R . R A & P

METHOD 02METHOD 01
Glucocorticoid Taper: 
The recovery period of impaired
mucosa would prolong if gastric acid
secretion increases
METHOD 03 METHOD 04
Prophylasix PPI Lansoprazole: 
Prevention of mucosa ulcer. Monitor
stool color, vital sign and Hb
POTENTIAL UGI BLEEDING
Stress Management: 
Relaxation and life style modification
Medication F/U: 
Antiplatelet agent Clopidogrel for CAD
side effect monitor
M R . R A & P

METHOD 02METHOD 01
S/S Monitor: 
Vital sign, physical examination, CXR,
blood test, sputum culture
NOTICE! SAMPLE 02
Respiratory Rehabilitation: 
Physical therapy for rehabilitation
program arrangement
No need of prophylasix antibiotics
usage without sign of infection! 
Deteriorate the digestive function of
bowels and increase the dosage of
Abx if further infection occurs
INFECTION CONTROL
M R . R A & P

COURSE
HOSPITAL
V I TA L S I G N , P E , L A B , M A N A G E M E N T, P R O G R E S S
I N PAT I E N T C O U R S E

VITAL SIGN, BW, PULSE OXYGEN SATURATION

STOOL

PRESCRIPTION

RESPIRATORY PT

LAB: BCS

LAB: HEMAGRAM

LAB: DIGESTIVE ENZYME; SERUM K

4
MINI-TOPIC
P O S T- I N T E N S I V E C A R E S Y N D R O M E
N E U R O M U S C U L A R W E A K N E S S R E L AT E D TO C R I T I C A L I L L N E S S  
PART04
PICS

PICS
INTRODUCTION
Although there is no official definition for post-intensive care syndrome (PICS), most clinicians agree that
PICS constitutes new or worsening function in one or more of the following domains after critical illness:
# Cognitive function
# Psychiatric function
# Physical function
IMPAIRMENT IN COGNITION, MENTAL HEALTH, AND PHYSICAL FUNCTION

D E F I N I T I O N
Inclusive of adult patients who reside in long term acute care rehabilitation units, skilled nursing facilities, and at home. 
Excludes patients admitted with traumatic brain injury and stroke.  
Usually identiﬁed in the immediate period following a critical illness.  
However, because symptoms are long lasting and the condition is under recognized, there is no set duration of time after a critical illness where PICS can or cannot occur 
Post-intensive care syndrome-family (PICS-F): Encompass the effects of critical illness on acute and chronic psychological morbidity among patients' family members. It is
considered the family response to the stress of critical illness in a loved one. It includes the symptoms that are experienced by family members during the critical illness as well as
those that occur following death or discharge of a loved one from the intensive care unit

> 1/2 SUFFER!
Risk factor: Prognostic sense
PUBLIC HEALTH BURDEN
EPIDEMIOLOGY 
RISK FACTORS
CLINICAL 
MANIFESTATION
DIAGNOSTIC 
EVALUATION
PREVENTION 
TREATMENT
LAST FOR M-Y
Newly-recognized or worsened after a
critical illness
WEAKNESS, POOR MOBILITY, POOR
CONCENTRATION, FATIGUE, ANXIETY,
DEPRESSED MOOD
UNRECOGNIZED
Ruling out other causes
H & P, TESTING,
CONSULTATION
MINIMIZES SEDATION
Treating the individual impairments with additional
referral to appropriate health care personnel
PRIORITIZES EARLY
PHYSICAL REHABILITATION
N E W S L I D E S

COGNITIVE
At 12 months post discharge, the
deﬁcits persisted for most patients.
25-78%
PSYCHIATRIC
Psychiatric illnesses also appear to
be common among survivors of
critical illness, with depression,
anxiety, and posttraumatic stress
disorder (PTSD) as the most common
disorders reported
1-62%
ICU-acquired weakness is the most
common form of physical impairment
occurring in 25 percent or more of
ICU survivors
25-73%
PHYSICAL
E P I D E M I O L O G Y

RISK
FACTORS
F O R P I C S
- Risk factors for the development of post-intensive care syndrome
(PICS) have not been clearly defined and vary depending on the
component of PICS that is studied.  
- Commonly cited risk factors can be broadly categorized into pre-
existing factors (eg, neuromuscular disorders, dementia, psychiatric
illness, comorbid conditions) and intensive care unit (ICU)-specific
factors (eg, mechanical ventilation, acute delirium, sepsis, acute
respiratory distress syndrome).  
- Whether ICU-related factors unmask pre-existing illness and to what
degree critical illness accelerates pre-existing neuropsychological or
functional decline is unclear, although some of this morbidity is likely
also entirely new.  
- The relative contributions of specific critical illnesses (eg, sepsis,
acute respiratory distress syndrome, stroke, trauma), as opposed to
general critical care (eg, frequent bedrest, excessive sedation,
inadequate treatment of delirium or hospitalization), have not been
addressed

COGNITIVE
• DELIRIUM
• PRIOR COGNITIVE DEFICIT
• SEPSIS
• ARDS
PSYCHIATRIC
Acute brain dysfunction (eg, alcoholism, stroke), hypoxemia
(eg, acute respiratory distress syndrome, cardiac arrest),
hypotension (eg, sepsis, trauma), glucose dysregulation,
respiratory failure (eg, prolonged mechanical ventilation…
SIMILAR TO THOSE FOR
COGNITIVE IMPAIRMENT
FOLLOWING CRITICAL ILLNESS
Prolonged mechanical ventilation
(more than seven days), sepsis, multi-
system organ failure, and as well as
prolonged duration of bedrest; ARDS,
systemic inﬂammatory response
syndrome, glucose dysregulation,
older age, and use of vasoactive
agents and corticosteroids
PHYSICAL
R I S K F A C T O R S
Severe sepsis and ARDS as well as respiratory failure,
trauma, hypoglycemia, and hypoxemia. Pre-existing anxiety,
depression, PTSD, female gender, age <50 years, lower
education level, pre-existing disability/unemployment…

MCLINICAL
A complex relationship exists between all
three components of PICS (cognitive,
psychiatric, physical), with impairment in
one domain frequently being associated
with new or worsening function in a
separate domain.
Conversely, physical rehabilitation
appears to decrease cognitive
impairment and psychiatric morbidity, as
well as improve physical function.
A N I F E S TAT I O N

COGNITIVE
• ATTENTION/CONCENTRATION
• MEMORY
• MENTAL PROCESSING SPEED
• EXECUTIVE FUNCTION
PSYCHIATRIC
• ANXIETY
• DEPRESSION
• POSTTRAUMATIC STRESS DISORDER (PTSD)
PHYSICAL
C L I N I C A L M A N I F E S T A T I O N S
• GENERALIZED POOR MOBILITY
• MULTIPLE FALLS TO QUADRIPARXSIS AND
TETRA PARESIS

DIAGNOSTIC
EVALUATION
Occupational and physical
therapists
Neuropsychologists
Psychiatrists
CONSULTATION
PICS is frequently unrecognized because neither screening nor formal testing have
traditionally been used in this population
Questionnaire
Pre-existing problems
Clinical course
HISTORY TAKING
Pulmonary function
Neuroelectrophysiologic testing
CONFIRMATORY TESTING

COGNITIVE
• THE MODIFIED MINI-MENTAL
STATE EXAMINATION (MMSE)
• THE MINI-COG
• THE MONTREAL COGNITIVE
ASSESSMENT (MOCA)
PSYCHIATRIC
• HOSPITAL ANXIETY AND DEPRESSION SCALE
AS A SINGLE INSTRUMENT TO ASSESS FOR
SYMPTOMS OF DEPRESSION AND ANXIETY
• BECK DEPRESSION INVENTORY AS AN
INSTRUMENT THAT EXAMINES FREQUENTLY
ENCOUNTERED SOMATIC COMPLAINTS
• BECK ANXIETY INVENTORY
• POSTTRAUMATIC STRESS SYNDROME 10-
QUESTIONS INVENTORY (PTSS-10)
PHYSICAL
D I A G N O S T I C E V A L U A T I O N
• FORMAL ELECTROMYOGRAPHY
• NERVE CONDUCTION STUDY
• HANDGRIP DYNAMOMETRY
• PULMONARY FUNCTION TESTS
(SPIROMETRY, LUNG VOLUMES, AND
DIFFUSING CAPACITY)
• EXERCISE TOLERANCE WITH A SIX MINUTE
WALK TEST
• NUTRITION ASSESSMENT

PREVENTION
AND
I N T E R V E N T I O N S
Prevention
• Awakening and Breathing Coordination with daily sedative interruption
and ventilator liberation practices
• Delirium monitoring and management
• Early ambulation in the ICU, when feasible
ICU Diaries
The use of an ICU diary maintained prospectively during the patient's
ICU stay by family members, healthcare providers, or both, has been
shown to decrease symptoms of posttraumatic stress disorder (PTSD)
Early ambulation/physical therapy
In general, our approach is to minimize sedation and mobilize ICU
patients as soon as is feasible, ideally on the ﬁrst ICU day
Treatment
• Cognitive deﬁcits can be treated with a combination of nonpharmacologic
and pharmacologic interventions
• Anxiety can be treated with pharmacotherapy, psychotherapy, and
nonpharmacologic therapy
• Physical dysfunction is usually treated with a multidisciplinary program
that includes exercise endurance and symptom management as well as
the provision of mobility aids and environmental adjustments

01C
riticalillness
m
yopathy
(C
IM
)is
the
m
ost
com
m
on
form
ofIC
U
-acquired
m
yopathy
02
C
riticalillness
polyneuropathy
(C
IP)is
anothercom
m
on
cause
ofneurom
uscularw
eakness
thatis
acquired
in
the
IC
U
,m
ostoften
as
a
com
plication
ofsevere
sepsis
03
Combined CIM and CIP, sometimes called critical illness polyneuromyopathy,
is increasingly recognized as a cause of neuromuscular weakness in the ICU
NEUROMUSCULAR
WEAKNESS
… Develops in approximately 25 percent or more of patients who are in the intensive care unit (ICU) and ventilated for seven or more days

01C
riticalillness
m
yopathy
(C
IM
)is
the
m
ost
com
m
on
form
ofIC
U
-acquired
m
yopathy
02
C
riticalillness
polyneuropathy
(C
IP)is
anothercom
m
on
cause
ofneurom
uscularw
eakness
thatis
acquired
in
the
IC
U
,m
ostoften
as
a
com
plication
ofsevere
sepsis
03
NEUROMUSCULAR
WEAKNESS
… Other considerations in the differential include rhabdomyolysis, cachectic myopathy, and Guillain-Barré syndrome

01C
riticalillness
m
yopathy
(C
IM
)is
the
m
ost
com
m
on
form
ofIC
U
-acquired
m
yopathy
02
C
riticalillness
polyneuropathy
(C
IP)is
anothercom
m
on
cause
ofneurom
uscularw
eakness
thatis
acquired
in
the
IC
U
,m
ostoften
as
a
com
plication
ofsevere
sepsis
03
NEUROMUSCULAR
WEAKNESS
… In survivors of CIP with mild or moderate nerve injury, recovery of muscle strength generally occurs over weeks to months. Treatment of CIP is supportive

THANKS
C H I A - C H I N G , C H E N
F O R Y O U R L I S T E N I N G A N D C O M M E N T S

86yo Male Weakness Post Pneumonia ICU

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