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*It is only for medical professionals to read for reference.
I can't find the cause of the disease after going round and round, but I have overlooked these details! The author of this article: attending physician at the People's Hospital of Licheng District, Jinan City, and Gao Guanglong's case express delivery on the day of admission: The patient was an elderly female, 66 years old, admitted to the hospital due to "recurrent confusion and dyspnea for 20 days"
.
History of present illness: 20 days before admission, the patient gradually developed confusion, slurred speech, unresponsiveness, shortness of breath, blue lips, cough, little sputum, no fever, chest pain, palpitations, abdominal pain, vomiting, convulsions, without obvious inducements, 20 days before admission.
He was treated with fluid infusion at the local clinic, but the symptoms could not be relieved, so he went to the emergency department of our hospital for treatment
.
Past history: The patient began to experience repeated chest tightness and lower extremity edema 3 years ago, shortness of breath and weakness in both lower extremities after walking 100 meters, which can be relieved after rest, and no systematic diagnosis and treatment; denies history of chronic cough and sputum, denies smoking and drinking alcohol History, no history of exposure to dust or smoke
.
Admission examination: body temperature 36.
4℃, pulse 96 beats/min, breathing 18 beats/min, blood pressure 85/50mmHg, SpO2 91%, BMI 24kg/m2
.
The patient is irritable and has no edema of the eyelids, pale conjunctiva and lips, and no palpable swelling of the thyroid gland
.
The thorax is not deformed, the lungs are percussively unvoiced, and a little moist rales can be heard in the lower lungs
.
Physical examination of the heart and abdomen showed no obvious abnormalities
.
There was no edema in both lower limbs
.
Both upper limb muscle strength and muscle tension are normal, both lower limb muscle strength is grade 3 to 4, muscle tension is normal, there is no muscle atrophy and muscle fasciculation, bilateral limb tactile sensation and joint position sensation are symmetrical and normal; two-finger nose test and heel Knee shin test is symmetrical and normal; bilateral Achilles tendon reflexes are positive
.
Bilateral pathological signs were negative, meningeal irritation signs were negative
.
The emergency department was immediately given blood tests and other tests, and the results reported: white blood cell count 11.
4×109/L (4.
0-10.
0), neutrophil ratio 66.
8% (45%-77%), hemoglobin 91g/L (110-160)
.
Blood gas analysis: pH 7.
198, PaCO2 76.
9mmHg, PaO2 49mmHg, HCO3- 21mmol/L, BE 10.
6mmol/L
.
ECG: sinus rhythm, ST segment depression (V4-V6)
.
Chest CT showed scattered exudate shadows and pleural effusion in both lungs
.
Admission diagnosis considerations: 1.
Hypotensive shock 2.
Type II respiratory failure, pneumonia, and pleural effusion.
Immediately after admission, endotracheal intubation is given, and ventilation is assisted by a ventilator
.
Give continuous pumping of dopamine to maintain blood pressure
.
At the same time, ceftriaxone for injection was given to control infection and improve related auxiliary examinations
.
Situation on the second day of admission: the results of the examinations: liver and kidney function, and troponin I are normal; ion analysis: blood sodium 128mmol/L (136-145); blood lipids: triglyceride 4.
01mmol/L (0.
4-1.
86) , Cholesterol 6.
58mmol/L (0-5.
2), low density lipoprotein 5.
1 mmol/L (2.
07-3.
1)
.
NT-ProBNP: 2282.
0pg/ml (0-300); five items of coagulation: D-dimer 1.
55ng/ml (0-0.
5); urine routine: urine protein (3+); blood gas analysis during ventilator treatment ：PH 7.
442, PaCO2 46.
2mmHg, PaO2 121mmHg, HCO3- 26mmol/L, BE 4.
6mmol/L
.
Imaging examination: CT of the brain showed bilateral lacunar foci in the basal nucleus, degeneration of white matter, and cerebral arteriosclerosis
.
Bedside cardiac color Doppler ultrasound: enlarged right atrium, widened pulmonary artery, moderate tricuspid valve regurgitation, pulmonary artery pressure of about 34mmHg, decreased left ventricular diastolic function, and a small amount of pericardial effusion
.
Full abdominal color Doppler ultrasound: a small amount of ascites
.
After completing the auxiliary examination, supplementary diagnosis will be given: cor pulmonale, cardiac function class II (NYHA classification), ascites, pericardial effusion, electrolyte imbalance, hyponatremia
.
Situation on the third day of admission: At this time, the patient's blood pressure can gradually be maintained without the use of dopamine, and the ventilator ventilation mode is gradually changed to P-SIMV mode to prepare for weaning
.
But the problem is that as long as the patient is weaned, the patient cannot breathe spontaneously for a long time.
If the patient is given two consecutive days to try to wean the machine, the ventilator cannot be withdrawn.
What's wrong? The diagnosis and treatment ideas are not limited, and the details of the disease should be paid attention to! Let's analyze these conditions in the patient: The electrolyte imbalance on the second day is easy to explain, which may be related to poor eating after the patient developed consciousness disturbance; respiratory failure is related to lung infection; cardiac color Doppler ultrasound appears in the right atrium Increased pulmonary artery pressure and lung infection can cause right ventricular overload and right heart insufficiency
.
Abdominal effusion may be related to right heart dysfunction
.
How about weaning difficulties? There are three common causes of weaning difficulties in our clinic: First, the underlying disease of the patient has not been fully controlled
.
If the lung infection is not fully controlled, the heart function is not completely corrected, or the central nervous system disease is not completely cured, etc.
, the patient may experience difficulty in weaning when weaning; second, the patient's general nutritional status is poor
.
Patients who use ventilator in clinical practice are more common in the elderly, and their nutritional status is poor.
They are mostly associated with hypoproteinemia and anemia.
The body is in a high metabolic state during mechanical ventilation.
When the nutrition is insufficient, it can cause respiratory muscle strength.
Respiratory function declines, and the ability to do work of breathing decreases, leading to weakness of the respiratory muscles and weak self-respiration.
Third, for patients with clear consciousness, psychological factors are also one of the main reasons for the difficulty of weaning
.
However, the patient’s own lung infection is not very serious, nor does he have a central nervous system disease.
The general physical condition is fine.
According to normal conditions, there should be no problem with weaning.
However, once the patient is weaned, it cannot be maintained for a long time.
Combined with other chronic diseases? With questions, let’s review some details of the medical history: 1.
The patient had recurrent lower extremity edema and multiple serous effusions this time; 2.
The patient’s dyspnea symptoms did not match the patient’s chest CT findings; 3.
In communicating with family members, I learned that patients often experience symptoms of drowsiness, chills, unresponsiveness, apathy, and loss of appetite
.
Based on the above three points, the physician in charge reconsidered the possible hypothyroidism of the patient
.
So the patient was immediately taken out of the five thyroid functions
.
really! Thyroid function: FT3: 0.
01pmol/L (3.
6-7.
5), FT4: 0.
05pmol/L (12-22), TSH 105uIU/ml (0.
27-4.
2), TPOAb>500 (<34), TGAb>450 (< 115)
.
At this time, the patient's hypothyroidism is basically clear, but combined with the patient's current course of disease, it should not be pure hypothyroidism, but combined with hypothyroidism
.
Hypothyroidism crisis, also known as mucinous edema coma, is the most serious condition of hypothyroidism
.
The main clinical manifestations have seven aspects: 1.
Decreased metabolism: The main manifestations of hypothyroidism in patients with hypothyroidism are dry skin, sparse hair, hoarseness, non-concave edema of the anterior tibia, large tongue, and delayed Achilles tendon reflex relaxation
.
2.
Mental disorders: Patients with hypothyroidism crisis may have symptoms of mental disorders such as lethargy, slow mental activity, memory loss, cognitive dysfunction, epilepsy, depression, apathy, lethargy, stupor, and coma
.
3.
Hypothermia: Almost all patients with hypothyroidism have hypothermia.
80% of patients with hypothyroidism have a body temperature of less than 35.
5 degrees Celsius.
Although the body temperature is low, the patient does not have chills
.
4.
Cardiovascular abnormalities: In hypothyroidism, patients with cardiovascular abnormalities may have increased diastolic blood pressure, decreased systolic blood pressure, and low pulse pressure
.
5.
Respiratory system: Respiratory depression often occurs in patients with hypothyroidism, which can lead to alveolar hypoventilation and progress to hypoxemia, eventually leading to carbon dioxide anesthesia and coma
.
6.
Gastrointestinal reactions: Many patients with hypothyroidism may have anorexia, nausea, abdominal pain, constipation, and abdominal distension.
Some patients have gastrointestinal reactions such as dysphagia and delayed epiglottis
.
7.
Infection: In patients with hypothyroidism, the most common infection is in the lungs, followed by urinary tract infections
.
Elderly patients have a poor response to infection and lack the body's response to infection such as fever, sweating, rapid heart rate, and increased leukemia
.
At this point in the analysis, almost all the clinical manifestations of the patient can be explained, so thyroid hormone and glucocorticoid were added to the treatment.
After nearly 2 weeks of treatment, the patient gradually got offline, his mental state improved, and his eating was normal.
He was transferred to the general ward steadily to continue treatment
.
The doctor has something to say that at first we thought this case was simple, but when we applied simple thinking to explain the occurrence and development of the disease, it was difficult to get through, so we discovered that seemingly simple diseases are not that simple.
.
Clinical thinking is actually the same as using soldiers to fight.
We must be good at discovering any small details of the patient, and we should consider the clinical symptoms of the patient as thoroughly as possible.
After all, any error in the details on the battlefield will lead to a turnaround in the battle.
.
On the "battlefield" of medical care, we must also consider as thoroughly as possible, because you are facing a life, and all colleagues are expected to be cautious!
I can't find the cause of the disease after going round and round, but I have overlooked these details! The author of this article: attending physician at the People's Hospital of Licheng District, Jinan City, and Gao Guanglong's case express delivery on the day of admission: The patient was an elderly female, 66 years old, admitted to the hospital due to "recurrent confusion and dyspnea for 20 days"
.
History of present illness: 20 days before admission, the patient gradually developed confusion, slurred speech, unresponsiveness, shortness of breath, blue lips, cough, little sputum, no fever, chest pain, palpitations, abdominal pain, vomiting, convulsions, without obvious inducements, 20 days before admission.
He was treated with fluid infusion at the local clinic, but the symptoms could not be relieved, so he went to the emergency department of our hospital for treatment
.
Past history: The patient began to experience repeated chest tightness and lower extremity edema 3 years ago, shortness of breath and weakness in both lower extremities after walking 100 meters, which can be relieved after rest, and no systematic diagnosis and treatment; denies history of chronic cough and sputum, denies smoking and drinking alcohol History, no history of exposure to dust or smoke
.
Admission examination: body temperature 36.
4℃, pulse 96 beats/min, breathing 18 beats/min, blood pressure 85/50mmHg, SpO2 91%, BMI 24kg/m2
.
The patient is irritable and has no edema of the eyelids, pale conjunctiva and lips, and no palpable swelling of the thyroid gland
.
The thorax is not deformed, the lungs are percussively unvoiced, and a little moist rales can be heard in the lower lungs
.
Physical examination of the heart and abdomen showed no obvious abnormalities
.
There was no edema in both lower limbs
.
Both upper limb muscle strength and muscle tension are normal, both lower limb muscle strength is grade 3 to 4, muscle tension is normal, there is no muscle atrophy and muscle fasciculation, bilateral limb tactile sensation and joint position sensation are symmetrical and normal; two-finger nose test and heel Knee shin test is symmetrical and normal; bilateral Achilles tendon reflexes are positive
.
Bilateral pathological signs were negative, meningeal irritation signs were negative
.
The emergency department was immediately given blood tests and other tests, and the results reported: white blood cell count 11.
4×109/L (4.
0-10.
0), neutrophil ratio 66.
8% (45%-77%), hemoglobin 91g/L (110-160)
.
Blood gas analysis: pH 7.
198, PaCO2 76.
9mmHg, PaO2 49mmHg, HCO3- 21mmol/L, BE 10.
6mmol/L
.
ECG: sinus rhythm, ST segment depression (V4-V6)
.
Chest CT showed scattered exudate shadows and pleural effusion in both lungs
.
Admission diagnosis considerations: 1.
Hypotensive shock 2.
Type II respiratory failure, pneumonia, and pleural effusion.
Immediately after admission, endotracheal intubation is given, and ventilation is assisted by a ventilator
.
Give continuous pumping of dopamine to maintain blood pressure
.
At the same time, ceftriaxone for injection was given to control infection and improve related auxiliary examinations
.
Situation on the second day of admission: the results of the examinations: liver and kidney function, and troponin I are normal; ion analysis: blood sodium 128mmol/L (136-145); blood lipids: triglyceride 4.
01mmol/L (0.
4-1.
86) , Cholesterol 6.
58mmol/L (0-5.
2), low density lipoprotein 5.
1 mmol/L (2.
07-3.
1)
.
NT-ProBNP: 2282.
0pg/ml (0-300); five items of coagulation: D-dimer 1.
55ng/ml (0-0.
5); urine routine: urine protein (3+); blood gas analysis during ventilator treatment ：PH 7.
442, PaCO2 46.
2mmHg, PaO2 121mmHg, HCO3- 26mmol/L, BE 4.
6mmol/L
.
Imaging examination: CT of the brain showed bilateral lacunar foci in the basal nucleus, degeneration of white matter, and cerebral arteriosclerosis
.
Bedside cardiac color Doppler ultrasound: enlarged right atrium, widened pulmonary artery, moderate tricuspid valve regurgitation, pulmonary artery pressure of about 34mmHg, decreased left ventricular diastolic function, and a small amount of pericardial effusion
.
Full abdominal color Doppler ultrasound: a small amount of ascites
.
After completing the auxiliary examination, supplementary diagnosis will be given: cor pulmonale, cardiac function class II (NYHA classification), ascites, pericardial effusion, electrolyte imbalance, hyponatremia
.
Situation on the third day of admission: At this time, the patient's blood pressure can gradually be maintained without the use of dopamine, and the ventilator ventilation mode is gradually changed to P-SIMV mode to prepare for weaning
.
But the problem is that as long as the patient is weaned, the patient cannot breathe spontaneously for a long time.
If the patient is given two consecutive days to try to wean the machine, the ventilator cannot be withdrawn.
What's wrong? The diagnosis and treatment ideas are not limited, and the details of the disease should be paid attention to! Let's analyze these conditions in the patient: The electrolyte imbalance on the second day is easy to explain, which may be related to poor eating after the patient developed consciousness disturbance; respiratory failure is related to lung infection; cardiac color Doppler ultrasound appears in the right atrium Increased pulmonary artery pressure and lung infection can cause right ventricular overload and right heart insufficiency
.
Abdominal effusion may be related to right heart dysfunction
.
How about weaning difficulties? There are three common causes of weaning difficulties in our clinic: First, the underlying disease of the patient has not been fully controlled
.
If the lung infection is not fully controlled, the heart function is not completely corrected, or the central nervous system disease is not completely cured, etc.
, the patient may experience difficulty in weaning when weaning; second, the patient's general nutritional status is poor
.
Patients who use ventilator in clinical practice are more common in the elderly, and their nutritional status is poor.
They are mostly associated with hypoproteinemia and anemia.
The body is in a high metabolic state during mechanical ventilation.
When the nutrition is insufficient, it can cause respiratory muscle strength.
Respiratory function declines, and the ability to do work of breathing decreases, leading to weakness of the respiratory muscles and weak self-respiration.
Third, for patients with clear consciousness, psychological factors are also one of the main reasons for the difficulty of weaning
.
However, the patient’s own lung infection is not very serious, nor does he have a central nervous system disease.
The general physical condition is fine.
According to normal conditions, there should be no problem with weaning.
However, once the patient is weaned, it cannot be maintained for a long time.
Combined with other chronic diseases? With questions, let’s review some details of the medical history: 1.
The patient had recurrent lower extremity edema and multiple serous effusions this time; 2.
The patient’s dyspnea symptoms did not match the patient’s chest CT findings; 3.
In communicating with family members, I learned that patients often experience symptoms of drowsiness, chills, unresponsiveness, apathy, and loss of appetite
.
Based on the above three points, the physician in charge reconsidered the possible hypothyroidism of the patient
.
So the patient was immediately taken out of the five thyroid functions
.
really! Thyroid function: FT3: 0.
01pmol/L (3.
6-7.
5), FT4: 0.
05pmol/L (12-22), TSH 105uIU/ml (0.
27-4.
2), TPOAb>500 (<34), TGAb>450 (< 115)
.
At this time, the patient's hypothyroidism is basically clear, but combined with the patient's current course of disease, it should not be pure hypothyroidism, but combined with hypothyroidism
.
Hypothyroidism crisis, also known as mucinous edema coma, is the most serious condition of hypothyroidism
.
The main clinical manifestations have seven aspects: 1.
Decreased metabolism: The main manifestations of hypothyroidism in patients with hypothyroidism are dry skin, sparse hair, hoarseness, non-concave edema of the anterior tibia, large tongue, and delayed Achilles tendon reflex relaxation
.
2.
Mental disorders: Patients with hypothyroidism crisis may have symptoms of mental disorders such as lethargy, slow mental activity, memory loss, cognitive dysfunction, epilepsy, depression, apathy, lethargy, stupor, and coma
.
3.
Hypothermia: Almost all patients with hypothyroidism have hypothermia.
80% of patients with hypothyroidism have a body temperature of less than 35.
5 degrees Celsius.
Although the body temperature is low, the patient does not have chills
.
4.
Cardiovascular abnormalities: In hypothyroidism, patients with cardiovascular abnormalities may have increased diastolic blood pressure, decreased systolic blood pressure, and low pulse pressure
.
5.
Respiratory system: Respiratory depression often occurs in patients with hypothyroidism, which can lead to alveolar hypoventilation and progress to hypoxemia, eventually leading to carbon dioxide anesthesia and coma
.
6.
Gastrointestinal reactions: Many patients with hypothyroidism may have anorexia, nausea, abdominal pain, constipation, and abdominal distension.
Some patients have gastrointestinal reactions such as dysphagia and delayed epiglottis
.
7.
Infection: In patients with hypothyroidism, the most common infection is in the lungs, followed by urinary tract infections
.
Elderly patients have a poor response to infection and lack the body's response to infection such as fever, sweating, rapid heart rate, and increased leukemia
.
At this point in the analysis, almost all the clinical manifestations of the patient can be explained, so thyroid hormone and glucocorticoid were added to the treatment.
After nearly 2 weeks of treatment, the patient gradually got offline, his mental state improved, and his eating was normal.
He was transferred to the general ward steadily to continue treatment
.
The doctor has something to say that at first we thought this case was simple, but when we applied simple thinking to explain the occurrence and development of the disease, it was difficult to get through, so we discovered that seemingly simple diseases are not that simple.
.
Clinical thinking is actually the same as using soldiers to fight.
We must be good at discovering any small details of the patient, and we should consider the clinical symptoms of the patient as thoroughly as possible.
After all, any error in the details on the battlefield will lead to a turnaround in the battle.
.
On the "battlefield" of medical care, we must also consider as thoroughly as possible, because you are facing a life, and all colleagues are expected to be cautious!
