Name: Ramona Mulan Age: 55 years old Admitted: ZCMC Date: August 20, 1997 Complain: Difficulty of breathing

3 days post-laparotomy The Case Ramona mulan, a woman of 55 had suffered from bronchial asthma for 10 years and had been treated with corticosteroids for 7 years. During this time she had had recurrent upper abdominal pain which was alleviated by alkalis and occasional courses of cimetidine. For 2 months before admission, she had been feeling unwell, tiring easily, with cough which troubled her during the day but which was unproductive of sputum. She was a non-smoker but her husband smokes heavily. One week before admission, her asthma worsened, and she increased her prednisolone intake to 40 mg/day. This produced improvement and she had reduced the dose to 20mg/day by the time of admission. Two hours before admission, she had developed sudden severe upper abdominal pain, and collapsed in the bus station on the way home. She was brought to the hospital instead. On examination she was very ill. BP 90/60, T-37C, PR 160/min. in the chest there was generalized expiratory wheezes, and dullness to percussion at the right base posteriorly extending into the axilla. There was generalized abdominal rigidity with diffuse tenderness. Bowel sounds were absent. Before laparotomy, she was given hydrocortisone, which was continued post operatively. At operation, there was free fluid in the abdomen and a small perforation of a posterior duodenal ulcer. The perforation was sutured. She made a good initial postoperative recovery, but on the third postoperative day she developed pyrexia of 39C which persisted. She was found to have dullness at the right mid to base with absent breath sounds and an area of bronchial breathing at the left base. She was treated with amoxicillin and erythromycin initially intravenously for 7 days, with improvement of the signs at the left base but without any effect on those at the right. A repeat chest x-ray at this time showed a right pleural effusion, patchy shadowing at the left base, and a calcified hilar lymph node. Laboratories: Oxygen saturation 70% X-ray: 1. Haziness at right lung field with obliteration at costophrenic angle 2. Widening intercostal space at left 3. Calcification of perihilar lymph nodes 4. At left decubitus position fluid layer along right costal gutter, mediastinal shift to the left, bronchial breath sounds at right base Hgb 12 grams WBC 15,000 Lymphocytes 56 Neutrophils 41 Eosinophils 0.03