critical and emergency care section II

(Medical emergencies and Adrenal insufficiency)

1506 514 3
(Pharmacotherapy 3)
16 .. 2558 13:00-16:00 .

SOAP Note
Subjective data :
78
CC : .
HPI : 5 PTA

COPD with AE with pneumonia

ceftriazone IV,Oral Roxithromycin,Dexamethasone IV,Beradual 1NB
q 4-6 hr
MH : Budesonide MDI 2 puff q 12 hr
SH :

( 6
) 6 2-3

.
ALL : NKDA
Objective data :
78 62 . 150 .
PE : GA : An elderly woman on ETT, Cushingoid facies and truncal
obesity

V/S : BP 96/61 mmHg, HR 130 bpm,BT 39.5 C

Heart : Tachycardia
Ext : no pitting edema , skin bruising at right arm
Lab : Hb = 8.7
Hct = 25.4
Lymphocyte = 7
WBC = 15,000
MCV = 7
PMN = 90.2%
Alb = 2.4
Morning cortisol level = 0.7
Bacteriological study : sputum G/S : numerous gram negative bacilli
and PMN
Impression: 1. HAP with respiratory failure
3.Anemia
2.Adrenal insufficiency
4. U/D
COPD,Hypertension & RA

Assessment :
76 62 kg .
COPD with pneumonia SIRS
HR = 130 bpm,BT = 39.5 qC WBC =
15,000/mm3 Sputum G/S
numerous gram
negative bacilli Sepsis


6 2-3
.
Cushingoid facie steroids FBS 57
mg/dL Hypoglycemia Na = 127 mEq/L
Hyponatremia cortisol Secondary
adrenal insufficiency crisis steroids
adrenal crisis

sepsis

Hyponatremia NSS 1-3
volume status 12-24 Hypoglycemia

50% Dextrose 20-50 ml IV push 5 min

adrenal crisis
hydrocortisone IV 100 mg
IV bolus 100 mg IV q 8 hr Stable
hemodynamics IV cortisone 50 mg q 6 hr
prednisolone 5mg/d 4-5
Plan :
- IV Hydrocortisone 100 mg IV push bolus then 100 mg q 8 hr
- NSS
- 50% Dextrose 20-50 mL IV push 5 min
Goal :

Efficacy monitoring : Na ,FBS

Toxicity monitoring : IV hydrocortisone :
PU,hyperglycemia,agitation,osteoporosis
Future plan :


vasopressor
hydrocortisone
fludrocortisone 0.1
mg
Patient education :
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