This 44-year-old male presented with progressive shortness of breath for one week. He had a history of weight loss, cough, and poor appetite. Physical examination revealed decreased skin turgor and crepitations on chest palpation. Chest X-ray and CT scan showed cavitary pulmonary tuberculosis with pneumothorax. Sputum tests were positive for Mycobacterium tuberculosis. The patient was diagnosed with pulmonary tuberculosis, acute respiratory failure, septic shock, and complications of pneumothorax and pneumomediastinum. He required intubation and mechanical ventilation in the intensive care unit.

1. 內科專科口試 107年度
姜冠宇 醫師

2. 題號 性別、年齡 主 述 診 斷 CASE有圖片，請
打勾(V)
是本人照顧，請打勾(V)
CASE 1. 41 y/o male; Dyspnea in 2 days. (V) ( )
Acute myopericarditis
CASE 2. 44 y/o Male ; Suddenly onset abdominal pain (V) (V)
Acute pancreatitis with acute respiratory failure
CASE 3. 44 y/o male ; Progress shortness of breath for 1 week (V) (V)
1. Pulmonary tuberculosis with cavitation
2. Acute respiratory distress syndrome
CASE 4. 66 y/o female ; general weakness for 5 days (V) (V)
Hyponatremia
CASE 5. 56 y/o female ; Fever up to 40’C with chills for 1 day (V) ( )
Infective endocarditis of mitral valve, Staphylococcus aureus(MRSA)
CASE 6. The 57-year-old female ; consciousness disturbance and fever for 1 day (V) ( )
Type II diabetes mellitus with hyperglycemic hyperosmolar state

3. Case 3 44 y/o male with progress shortness of breath for 1 week

4. CASE 3. 病例摘要
主訴：
Progressive shortness of breath for 1 week
簡單病史：
This 44-year-old divorced male has no systemic disease, according to his mother. This time, he was admitted for progress
shortness of breath for 4 days. In recent one month, his mother mentioned that the patient had rapid body weight loss,
cough, and poor appetite noted. In recent 4 days, the patient had progressive weakness and complained about throat
soreness and general weakness. today the patient was found weakness and shortness of breath and was sent to ER. There
is no fever, no chillness, no nausea and vomiting, no chest pain, no abdominal pain complained.
At the ER, his vital signs were TPR 37.8/144/24 SpO2 97%. CXR and CT showed Active pulmonary TB with cavitation was
suggested.And Small amount of pneumothorax and pneumomediastinum. subcutaneous emphysema at right chest wall
and bilateral neck.For progress dyspnea and O2 desaturation, the patient was intubated. After for shock, levophed and
hydration was given. Under the impression of TB and septic shock with multiple organ dysfunction, the patient was
admitted to ICU for further care.

5. Chief Complain
Progress shortness of breath for 1 week
Past history
Workman; Divorced
Smoking (-) ; Alcohol (-)
No medical history before; Allergy unknown
TOCC (-)
Patient

6. Patient illness
Poor appetite
Weight loss about 6Kg within 1 month
Weakness and Bed-rest > 1 week
RR PR BT SBP DBP
25 141 35 84 56
Con’s alert, E4M6Vt
Vital sign

7. Physical Examination
Acute ill / Cachexia looking
Decrease in skin turgor
Crepitation on palpation over chest
Chest: Bilateral Coarse
Heart: Regular heart beat, No Murmur
Abdomen: Flat Soft, Normoactive, No
tenderness

11. ABG
PH 7.475
PCO2 25.4 mmHg
PO2 72.2 mmHg
HCO3- 18.3 mmol/L
BE -3.8 mmol/L
O2Sat 95.7 %
Lab data
Bio
Na 126 mmol/L
K 5.6 mmol/L
Bil-T. 0.9 mg/dL
GOT 111 IU/L
GPT 22 IU/L
Ammonia 61 umol/L
Glucose 118 mg/dL
CPK 171 IU/L
CK-MB 31 U/L
Tn-T 13.2 ng/L
Lactate 4.79 mmol/L
BUN 45 mg/dL
Cr 1.25 mg/dL
CBC
HGB 12.7 g/dL
HCT 39.3 %
MCV 73.0 fL
WBC 21.78 10 3/μL
WBC DC
Neutrophil 98.0 %
Lymphocyte 0.0 %
Monocyte 2.0 %
Eosinophil 0.0 %
Basophil 0.0 %

12. ABG: PaO2/FiO2
AFB Result Sputum Positive 4+
→TB PCR (+)
→TB culture: M.tuberculosis

13. 1. Acute respiratory failure, s/p intubation with MV since 2016/12/5
2. Septic shock
3. Suspect Pulmonary tuberculosis
4.Community acquired pneumonia
5. Pneumothorax and pneumomediastinum
6. Subcutaneous emphysema
7. Hyponatremia
8. Hyperkalemia
Impression