This 79 years old male patient living at home had a past history of 1)old CVA, 2)parkinsonism, 3)arrythmia, 4)CAD without follow up since 2008 and 5)left hip fracture for one year without treatment since 2012/06. Bedridden status was noted after left hip fracture caused by a falling down. Chronic cough with sputum was mentioned by family.
This time he was noted fever with shortness of breath on 11/11 night. There was no obvious chill, nausea, diarrhea. Chest tightness and vomiting twice were noted. In ER, GCS showed E1V1M4. Vital signs showed tachycardia and tachypnea. Physical examination showed deep sacral pressure sore and bilateral rales breath sound. Lab data showed leukocytosis, high lactate and elevated liver enzyme. Intubation was done due to acute respiratory failure. Under the impression of septic shock and acute respiratory failure, he was admitted to ICU for treatment.
- KookieLv 55 年前最佳解答
[英翻中] ICU Medical Record.
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- 5 年前
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