內科 & er conference 內科 r3 張哲嘉 /f1 侯羿州 指導醫師 : 腎臟科 顏宗海...
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內科 & ER conference內科 R3 張哲嘉 /F1 侯羿州
指導醫師 : 腎臟科 顏宗海 醫師
Basic data
•Chart number:2399xxx•Name : 丁 OO•Gender: male•Age:57 y/o•Occupation: Chemical engineering
teacher•Marriage: married•Admission date: 2011.01.30
Chief complaint
• Taking arsenic in the afternoon at 14:00
Present illness
•This 57 years old male chemistry engineering teacher.
•He had stress in recent one month, with negative thought and insomnia.
•He took 30 gm arsenic( 砒霜 ) this afternoon at 14:00.
Present illness
•Nausea and vomiting with gastric juice content vomitus was noted.
•General weakness, dizziness were also mentioned.
•No chest pain, no dyspnea, no abdominal pain, no diarrhea.
Present illness
•He was found by his co-worker, and sent to our ER.
•At ER, progressive hypotension was noted with hypoxic respiratory failure , metabolic acidosis, and acute kidney injury.
•Intubation was performed and under high does inotropic agent, he was admitted to ICU.
Past history• Hypertension, under medical control for years,
with daily systolic pressure 130~140mmHg• Peripheral vertigo under medical control for 10
years
• Denied Diabetes mellitus, coronary artery disease, cerebral vascular accident, hepatitis B, hepatitis C,
• Operation history:▫Urolithiasis underwent ESWL 10 years ago
Personal History
•Allergy: denied known allergen•Alcohol: no•Smoking : no•Betelnut : no
Family History85, dementia
25 27
57 57
Review of system
•General: Appearance:acute-ill looking
Consciousness: clear Development: fair Weakness:(YES) Fatigue:(no) Fever:(no) Chill:(no) •Head: Headache:(no) Dizziness:(YES) •Neck: Stiffness:(no) •Resp Sys: Dyspnea:(YES) Wheezing:
(no) Cough:(no) Sputum:(no) Hemoptysis:(no)
Review of system• CV: Chest tightness:(no) Chest pain:(no)
Exertional dyspnea:(no) Orthopnea:(no) P.N.D:(no) Palpitation:(no) Tachycardia:(no) Bradycardia:(no)
• GI: Dysphagia:(no) Anorexia:(no) Nausea:(YES) Vomiting:(YES) Diarrhea:(no) Constipation:(no) Abdominal pain:(no) Abdominal distention:(no)
• Urinary: Dysuria:(no) Urgency:(no) Polyuria:(no) Oliguria:(YES) Hematuria:(no) Nocturia:(nO)
Physical examination• T:36.8/℃ P:151/min R:28/min
BP:68/44/mmHg•GENERAL APPEARANCE: acute ill •CONSCIOUSNESS: drowsiness , E 3 V e
M 5 -6•Peripheral cyanosis, cold•HEENT: Sclerae: NOT icteric Conjunctivae:
NOT pale
•NECK: Supple
Physical examination
•CHEST: ▫ Breath pattern: Distress, Bilateral
symmetric expansion ▫ USE OF accessory muscles ▫ Breathing sound:Bilateral coarse
•HEART: Tachycardia without audible murmur No audible S3; No audible S4
Physical examination
•ABDOMEN: ▫ Soft AND flat, Liver AND spleen NOT
palpable , No shifting dullness ▫No tenderness; No rebounding pain ;No
muscle guarding , tympanic▫Bowel sound: hypooactive
•BACK: No knocking pain over bilateral flank area
•EXTREMITIES: No joint deformity, No pitting edema
LAB 血液 12/30 1613
WBC /uL 11800
Hb g/dL
15.3
Hct % 46.1
MCV fL 87.5
PLT 1000/uL
179
Seg 91.4%
Lym 5.9%
Mono 2.7%
Baso 0.0%
Eosin 0.0%
生化 12/30 1613
ALT 103
Bil (T) 1.0
Cr 1.4
Na 137
K 3.7
LAB12/30 1609
12/30 2105
12/30 2247
PH 7.394 7.331 7.271
P CO2 34.7 23.5 38.7
PO2 19.6 82.9 46.1
HCO3 20.7 12.1 17.4
SAO2 31.5% 95.8% 76.5%
Vein gas
CXR 12/30 post intubation
12/30 KUB
Impression
•Arsenic intoxication •Acute hypoxemic respiratory failure, post
intubation with mechanical ventilator support, may due to 1.
•Acute kidney injury•Suicide attempt
Plan
•Give chelating agent Dimaval 250mg/5ml/amp (DMPS) 1 amp q12h IVF
•Follow As level • Adequate hydration and inotropic agent
use•Sodium bicarbonate for correct metabolic
acidosis
Hospital course
12/30 23:10, HR:151, BP 68/44mmHg, CVP level: 4cmH2O
12/30 23:49, HR:144 BP:108/92mmHg IVF:D5S run 120ml/hr, Sod. bicarbonate run 20ml/hr
12/31 00:30 Irritable, midazolam 2.5mg IV statSBP:70~8o mmHgFluid challenge with N/S 1000 ml
Dopamine 50ml/hr,(20mcg/kg/min)check hemogram , biochemistry and ABG
Fluid challenge with N/S 1000 mlLevophed 40(20mcg/min)=> 50ml/hr(26mcg/min)
LAB• 12/30 1609• 12/30 2105• 12/30 2247• PH• 7.394• 7.331• 7.271• P CO2• 34.7• 23.5• 38.7• PO2• 19.6• 82.9• 46.1• HCO3• 20.7• 12.1• 17.4• SAO2• 31.5%• 95.8%• 76.5%
• Vein gas
血液 12/31 0046
WBC /uL 49600
Hb g/dL
15.4
PLT 1000/uL
166
Atypical-Lympho
0.3%
Meta-Myelocyte
1.0%
Seg 73%
Band 12.7%
Lym 10%
Mono 2.7%
Baso 0.3%
Eosin 0.0%
生化 12/31 0046
BUN 15.9
Cr 3.68
ALT 98
Ca 7.4
P 3.5
Na 145
K 2.8
Cl 115
Tn I 20.958
Lactate 99.9
ABG 12/31 0041
PH 7.150
P CO2 34
PO2 225.5
HCO3 11.6
SAO2 99.2%
FiO2 80%
AaDO2 309
12/30 23:10, HR:151, BP 68/44mmHg, CVP level: 4cmH2O
Fluid challenge with N/S 1000 mlLevophed 40(20mcg/min)=> 50ml/hr(26mcg/min)
12/30 23:49, HR:144 BP:108/92 IVF:D5S run 120ml/hr, Sod. bicarbonate run 20ml/hr
12/31 00:30 Irritable, midazolam 2.5mg IV statSBP:70~8o mmHg
Fluid challenge with N/S 1000 mlDopamine 50ml/hr(20mcg/kg/min)
Contact with nephrologist for CVVHD
12/31 1:06 HR: 45 BP:45/32 mmHg, than PEA, CPCR, Critical AAD.
Arsenic level (1.5 hrs after patient ingestion)•730 ug/L (<20 ug/L )
Final diagnosis
•Arsenic intoxication, with multiple organ failure
•Commit suicide
Thanks for your attention!!