Field Details
Patient Name Dr. Garett Hernandez Bales
Gender Male
Medical Record Number BN/4564-4655/24
Referring Facility Army Medical Facility, Irwin Barracks
Attending Physician A. Robert Arntfield
Reason for Admission
The patient was admitted with severe respiratory distress following acute symptoms of hypoxemia, including difficulty breathing, cyanosis, and profound fatigue. Initial assessments indicated compromised lung function and reduced oxygen saturation levels despite supplemental oxygen therapy.
Physical Examination Findings
Vital Signs Details
Temperature 37.6°C
Blood Pressure 105/65 mmHg
Heart Rate 120 bpm (tachycardia)
Respiratory Rate 28 breaths per minute
SpO2 84% on room air, improved to 91% with high-flow oxygen
Category Details
General Appearance Acute distress, visibly fatigued, and pale.
Cardiopulmonary Findings Diminished breath sounds bilaterally. Fine crackles noted in the lower lung fields. No significant murmurs or jugular venous distention.
Investigations
Test Results
ABG pH: 7.35, PaO2: 55 mmHg, PaCO2: 42 mmHg
Chest X-ray Bilateral ground-glass opacities in lower lobes.
CT Scan of Thorax Diffuse interstitial lung disease pattern.
Blood Tests Elevated D-dimer, CRP: 85 mg/L, Ferritin: 400 ng/mL
Pulmonary Function Test FVC: 45%, DLCO: 38% of predicted.
Diagnosis
Primary Diagnosis Details
Acute Hypoxemic Respiratory Failure Due to Severe Interstitial Lung Disease
Secondary Diagnosis Suspected ARDS with microvascular complications
Treatment and Interventions
Category Details
Supportive Care High-flow oxygen, ECMO initiated.
Pharmacological Therapy Methylprednisolone IV, broad-spectrum antibiotics.
Specialized Diagnostics Bronchoscopy, lung biopsy.
Multidisciplinary Teams Pulmonology, critical care, hematology.
Current Status
The patient remains in ICU under continuous monitoring. Oxygenation parameters are stable but reliant on ECMO. Further investigations to determine lung pathology are ongoing.