1. S
1.still shock status under moderate dose of vasopressor
-> progressive acidosis and still fever/dyspnea/tachycardia
-> still lower CVP level but increase ABP after aggravating hydration
-> alert consciousness and improved tissue perfusion sign
2.still auria due to BPH obstruction
-> bedside echo: distended bladder but no hydronephrosis
3.delayed gastric emptying time and poor GI digestive function
-> hypoglycemia episode after glucose water supply
O
* Fluid status-- Input/output: +2781 ml/day; Urine output: 0 ml/day
* CVP level-- +7 mmHg
* F/S: 67 mg/dl(9pm)-> 131 mg/dl(6am)
<< Physical examination >>
* Consciousness: alert, GCS: E4VeM6, Orientation: OK
* Vital sign: BP: 112/70mmHg (Levophed), PR: 114 bpm, RR: 26cpm,
BT: 38.2 degree, SpO2: 100% (FiO2: 40%)
* Conjunctiva: not pale, Sclera: not icteric
* Chest: HS: regular heart beat, tachycardia(+), distant(+)
BS: coarse crackles, bilateral
* Abdomen: soft/flat, no tender, tympanics(-), bowel sound: hypoactive
distended bladder(+)
* Extremity: no pitting edema on bilateral lower legs
<< Lab data & Image >>
- Albumin: 2.1 g/dl, ALP/rGT: 81/52 mg/dl, Bil(T/D): 1.0/0.6 mg/dl
- Chol/TG: 91/69mg/dl, UA: 4.6mg/dl, LDL: 28mg/dl, Ca/P: 7.3/2.5 mg/dl
- ABG: pH:7.377, PaO2:99.2, PaCO2:29.5, HCO3:16.9, P/F ratio: 198.4
A
1.Septic shock
-> superimposed with critical illness related adrenal insufficiency
2.Acute repisratory failure s/p intubation(2/25) with MV support
3.Pneumonia, bilateral, community-acquired
4.Obstructive uroapthy, benign prostate hypertrophy related
5.Hypoalbuminemia, with pre-renal azotemia
6.Hypocalcemia
7.old Pulmonary Tuberculosis with destructive lung
8.Cachexia
P

2. 1.aggravating hydration with N/S + albumin for shock
-> shift vasopressor from Dopamin to Norepinephrine for septic shock
-> add on stress-dose steroid; correct electrolyte imbalance
2.keep current empirical antibiotics treatment with Cefotaxime
-> pursue microbiology study report
-> intensive chest care and mucolytics & MV support
3.contact with Urologist for cystostomy to relief obstructive uropathy
4.add on prokinetics for delayed gastric emptying time
-> insulin protocol for dysglycemia control
5.closely monitor of fluid status, hemodynamic
S
low grade fever
dyspnea
tachycardia
still auria
P
Ventilatoe : PCV mode FiO2: 40%, EPEP:5, rate:12
Vital signs: BT=36.8 °C, PR=163 bpm, RR=28 cpm, BP= 105/48 mmHg SP02: 97%
(MV)
Consciousness: GCS: E4VeM6(sedtation)
Conjuctiva: not pale, Sclera: not icteric
Breathing sound: crackle coarse over bilateral lung field,expiratory wheezing(-)
Heart sound: irregular heart sound
Abdomen: soft ,no tenderness ,no muscle guarding,no knocking pain
bowel sound: normoactive, distended bladder(+)
Extremity: no pitting edema of bilateral lower legs
A
1.Septic shock
-> superimposed with critical illness related adrenal insufficiency
2.Acute repisratory failure s/p intubation(2/25) with MV support
3.Pneumonia, bilateral, community-acquired
4.Obstructive uroapthy, benign prostate hypertrophy related
5.Hypoalbuminemia(02/26 Alb:2.1), with pre-renal azotemia
6.Hypocalcemia(02/26 Ca:7.3)
7.old Pulmonary Tuberculosis with destructive lung
8.Cachexia

3. P
Ventilator support
20% Albumin 1BOT QD X 3day(02/26~02/28)fro hypoalbuminemia
Antibiotic with cefotaxime 1vial Q8H for Pneumonia, bilateral, community-acquired
monitoring finger sugar QID/ac wih SSI
Steroids with solu-cortef(100mg)0.5vila Q6H and Aminophylline 1# QID
monitoring hemodynamic and fever pattern change
check CVP level and wound QD care
closely monitoring respiratory pattern and Spo2 level
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