CASE I
PATIENT DATA
BASE
A.
Patient Description:
- Name : ABM
- Age : 34 years
- DOA : 03/08//07
- Gender : Male
- Race : Mala
- RN : 598912
- Ward : ICU/B5
B. Chief complaint:
Found lost of conscious in his room by family
members.
C.
History of present illness:
ABM is a 34
year-old man brought to ICU by ambulance on 3rd of August 2007 after
found unconscious in the room by his family members. According to sister, he
locked all the doors before attempting suicide in his room. Family members had
to break the door to enter.
D.
Past Medical History
No known medical
illness.
E. Family/Social
History
·
Not significant.
·
Non smoker. Non alcoholic.
·
According to sister – No problem at
home/girlfriend/finance.
·
According to mother – He has some family
problems. He always isolated himself.
F. Allergies
NKDA.
G. Past Medication History
Could not be obtained.
H. Review of System
·
O/E – Patient confused
-
Dry mucous membrane
- Pupil
constricted 1mm both side
-
Smelly – like pesticide
·
BP – 120/80
·
P – 40 beats/min (bradycardia) – after given 1
amp of atropine, P – 110.
·
GCS – E – 4, V – 1, M – 2 =
7/15
·
Lungs – crepitation
I. Laboratory
Investigation
DATE
|
3/8
|
4/8
|
5/8
|
6/8
|
7/8
|
|
BLOOD
CHEMISTRY
|
NORMAL
|
|||||
Na+
|
135-145
mmol/L
|
144
|
144
|
139
|
136
|
139
|
K+
|
3.5-5.0
mmol/L
|
3.1
|
3.4
|
3.3
|
3.2
|
3.6
|
BUN
|
1.7-8.3
mmol/L
|
6.1
|
2.5
|
1.7
|
2.2
|
3.3
|
Creatinine
|
57-130
mmol/L
|
168
|
80
|
83
|
81
|
82
|
Cl
|
96-106
mmol/L
|
101
|
110
|
104
|
101
|
102
|
Cr Cl
|
75-125
ml/min
|
|||||
Mg+
|
0.8-1.0
mmol/L
|
1.18
|
||||
Ca2+
|
2.1-2.55
mmol/L
|
2.58
|
2.38
|
|||
PO4
|
0.89-1.40 mmol/L
|
3.14
|
1.32
|
|||
HEMATOLOGY
|
||||||
Hct
|
36-46%
|
45.2
|
35.9
|
39.9
|
37.1
|
34.2
|
HgB
|
12-16g/dl
|
14.8
|
12.1
|
12.9
|
11.7
|
10.8
|
WBC
|
4.5-11
x109/L
|
15.3
|
14.7
|
5.9
|
5.3
|
4.2
|
RBC
|
4.7-6.1
x 1012/L
|
5.6
|
4.5
|
4.8
|
4.4
|
4.1
|
PLT
|
130-400
x103/mml
|
226
|
185
|
150
|
131
|
155
|
LYM
|
16-45%
|
|||||
NEUT
|
45-74%
|
|||||
LIVER FT
|
||||||
PT
|
10.7-13.7
sec
|
11.8
|
13.6
|
12.1
|
13.1
|
12.1
|
INR
|
1.0-1.24
|
1.0
|
1.1
|
1.0
|
1.1
|
1.0
|
APPT
|
25-40
sec
|
25.2
|
29.9
|
26.3
|
26.9
|
25.6
|
CARDIAC
ENZYMES
|
||||||
AST
|
1-37U/L
|
42
|
||||
LDH
|
50-150U/L
|
305
|
||||
CK
|
0-130U/L
|
110
|
||||
ABG
|
||||||
pH
|
7.35-7.45
|
7.13
|
7.35
|
7.44
|
7.35
|
7.36
|
PO2
|
75-100 mmHg
|
177
|
176
|
183
|
161
|
170
|
PCO2
|
35-45 mmHg
|
46
|
53
|
43
|
52
|
59
|
HCO3
|
24-28 mmol/L
|
15.3
|
29.3
|
29.2
|
28.7
|
33.3
|
SPO2
|
90-95%
|
|||||
Plasma
Cholinesterase
|
4620
- 11500
|
405
|
366
|
327
|
271
|
DATE
|
3/8
|
4/8
|
5/8
|
6/8
|
7/8
|
|
NORMAL
|
||||||
LIVER FT
|
||||||
Total Protein
|
66-87g/L
|
96
|
53
|
68
|
||
Albumin
|
38-51g/L
|
59
|
34
|
40
|
||
Globulin
|
20-36
|
37
|
19
|
28
|
||
Tot bilirubin
|
0-24mmol/L
|
1.6
|
1.8
|
1.4
|
||
ALT
|
0-42U/L
|
101
|
26
|
12
|
||
ALP
|
34-104U/L
|
89
|
50
|
27
|
||
AST
|
0-24mmol/L
|
41
|
55
|
|||
DATE
|
8/8
|
9/8
|
10/8
|
11/8
|
||
BLOOD
CHEMISTRY
|
NORMAL
|
|||||
Na+
|
135-145
mmol/L
|
135
|
136
|
133
|
137
|
|
K+
|
3.5-5.0
mmol/L
|
4.4
|
3.9
|
4.7
|
4.4
|
|
BUN
|
1.7-8.3
mmol/L
|
3.5
|
5.3
|
6.2
|
6.3
|
|
Creatinine
|
57-130
mmol/L
|
75
|
78
|
93
|
77
|
|
Cl
|
96-106
mmol/L
|
100
|
98
|
98
|
102
|
|
Cr Cl
|
75-125
ml/min
|
|||||
Mg+
|
0.8-1.0
mmol/L
|
1.19
|
1.09
|
|||
Ca2+
|
2.1-2.55
mmol/L
|
2.67
|
||||
PO4
|
0.89-1.40 mmol/L
|
1.28
|
||||
HEMATOLOGY
|
||||||
Hct
|
36-46%
|
34.8
|
33.3
|
33.9
|
32.0
|
|
HgB
|
12-16g/dl
|
11.3
|
10.8
|
10.8
|
10.2
|
|
WBC
|
4.5-11
x109/L
|
6.7
|
6.8
|
7.8
|
6.9
|
|
RBC
|
4.7-6.1
x 1012/L
|
4.2
|
4.0
|
4.0
|
3.8
|
|
PLT
|
130-400
x103/mml
|
179
|
208
|
261
|
269
|
|
LYM
|
16-45%
|
|||||
NEUT
|
45-74%
|
|||||
LIVER FT
|
||||||
PT
|
10.7-13.7
sec
|
12.4
|
12.3
|
12.2
|
11.9
|
|
INR
|
1.0-1.24
|
1.0
|
1.0
|
1.0
|
1.0
|
|
APPT
|
25-40
sec
|
24.5
|
24.7
|
23.9
|
23.1
|
|
CARDIAC
ENZYMES
|
||||||
AST
|
1-37U/L
|
|||||
LDH
|
50-150U/L
|
|||||
CK
|
0-130U/L
|
|||||
ABG
|
||||||
pH
|
7.35-7.45
|
7.39
|
7.38
|
7.36
|
7.40
|
|
PO2
|
75-100 mmHg
|
177
|
188
|
187
|
157
|
|
PCO2
|
35-45 mmHg
|
49
|
51
|
50
|
52
|
|
HCO3
|
24-28 mmol/L
|
29.7
|
30.2
|
28.2
|
32.2
|
|
SPO2
|
90-95%
|
|||||
Plasma
Cholinesterase
|
4620
- 11500
|
298
|
273
|
DATE
|
12/8
|
13/8
|
14/8
|
15/8
|
||
BLOOD
CHEMISTRY
|
NORMAL
|
|||||
LIVER FT
|
||||||
Total Protein
|
66-87g/L
|
94
|
||||
Albumin
|
38-51g/L
|
49
|
||||
Globulin
|
20-36
|
45
|
||||
Tot bilirubin
|
0-24mmol/L
|
1.1
|
||||
ALT
|
0-42U/L
|
37
|
||||
ALP
|
34-104U/L
|
92
|
||||
AST
|
0-24mmol/L
|
|||||
J.
Drug Treatment in The Ward
Drug Name
/ Route
|
Dose /
Frequency
|
Duration
|
Indication/Safety/Efficacy
|
Start-Stop Date
|
|||
I.V Atropine
|
3/8 -
|
||
I.V Augmentin 1.2g
|
Stat & TDS
|
3/8 – 10/8
|
|
I.V Metronidazole 500mg
|
TDS
|
3/8 – 11/8
|
|
Activated Charcoal 25mg
|
Stat & QID
|
3/8 – 11/8
|
|
I.V Sodium
Bicarbonate 10ml/hr
|
3/8 – 4/8
|
||
I.V Ranitidine
50mg
|
TDS
|
3/8 – 8/8
|
|
I.V Calcium
Gluconate 1g
|
Stat & BD
|
3/8 – 8/8
|
|
I.V Metoclopramide
10mg
|
Stat & TDS
|
5/8 – 10/8
|
|
Mist KCL 1g
|
TDS
|
6/8 -
|
|
I.V MgSO4
10mmol/L
|
7/8 -
|
||
T. Ranitidine 150mg
|
ON
|
8/8 -
|
|
S/C Heparin
5000 Unit
|
Stat & BD
|
8/8 -
|
|
T. Alprazolam
0.5mg
|
BD
|
9/8 -
|
|
I.V Haloperidol
5mg
|
Stat & PRN
|
9/8 -
|
Date
|
3/8/07
|
4/8/07
|
5/8/07
|
6/8/07
|
|
General |
Patient
confused
Dry
mucous membrane
Pupil constricted 1mm – both side
Aspiration Pneumonia?
Insecticide smell from mouth
Metabolic acidosis
Mild liver impairment – treated as PCM
poisoning
|
Open eyes to call
Obey command
Acidosis improve after HD & I.V NaHCO3
PCM level normal
Salicylate level normal
Pupils still constricted
|
Metabolic acidosis resolved
Pupils 3mm/3mm
ABG – good gas exchange
Blood C&S no growth
Yellowish secretion
Vomiting
|
Restless and twitching
Pupils 2mm/2mm
UO 100ml/hr
|
|
Vital signs
|
BP
|
120/80
|
111/57
|
124/66
|
130/70
|
ABP
|
|||||
PR
|
110
|
113
|
110
|
116
|
|
RR
|
|||||
T
|
37
|
37
|
38.5
|
37
|
|
CVP
|
16
|
6
|
7
|
||
O2Sat
|
99
|
100
|
|||
CVS
|
|||||
Plan/Action Taken
|
I.V Flumazenil
I.V Atropine
1.8ml/hr – titrate to HR > 120 and Pupil > 4mm
I.V Augmentin
1.2g Stat & TDS
I.V Naloxone
I.V Metronidazole
500mg TDS
Activated Charcoal
50mg Stat & 25mg QID
I.V Sodium Bicarbonate 10ml/hr
I.V Ranitidine 50mg TDS
I.V Calcium
Gluconate 1g Stat & BD
I.V N-Acetycysteine
I.V Midamorphine
Hemodialysis
|
Cont treatment
I.V Pralidoxine 1g Stat
I.V Propofol
30mg/hr
Off I.V NaHCO3
Off I.V Metronidazole
Off Activated Charcoal
Transfusion 2 pint FFP
Off Calcium Gluconate
|
Adjust Atropine
to keep HR > 120 and Pupil > 4mm
I.V Metoclopramide 10mg Stat & TDS
|
Mist KCL 1g TDS
|
|
Daily Progress Report
Daily Progress Report
Date
|
7/8/07
|
8/8/07
|
9/8/07
|
10/8/07
|
11/8/07
|
|
General |
Pupils 3mm/3mm
Patient restless
Obey commands
|
Blood C & S Klebsiella pneumonia sensitive to Augmentin
Pupils 3mm/3mm
|
Urine output 80ml/hr
Pupils 2mm/2mm – sluggish to light
Imp – unlikely methanol poisoning
|
Alert, conscious, obeys command
ABG good gas exchange
Pupils 3mm/3mm – reactive to light
|
Patient stable
Pupils 3mm/3mm
|
|
Vital signs
|
BP
|
116/76
|
144/79
|
120/79
|
133/84
|
114/88
|
ABP
|
||||||
PR
|
126
|
93
|
89
|
117
|
98
|
|
RR
|
||||||
T
|
37
|
37.5
|
38
|
37.5
|
||
CVP
|
13
|
10
|
10
|
|||
O2Sat
|
99
|
99
|
100
|
100
|
||
CVS
|
||||||
Plan/Action Taken
|
I.V MgSO4 10mmol/L
Daily FFP transfusion
Intubated
|
I.V changed to T. Ranitidine 150mg ON
S/C Heparin
5000 unit Stat & BD
|
Tepid Sponging
Cont treatment
|
Off Maxolon
Off Augmentin
|
T. Alprazolam
0.5mg BD
I.V Haloperidol
5mg Stat & PRN
|
|
MICROBIOLOGY TESTS
Source
|
Date
|
Results
|
Sensitive to
|
Resistant to
|
Urine
|
3/8
|
No Growth
|
-
|
-
|
Blood
|
4/8
|
No Growth
|
||
Nasal
|
5/8
|
No Growth
|
||
Blood
|
5/8
|
No Growth
|
||
Urine
|
6/8
|
No Growth
|
||
Lumen catheter
|
7/8
|
Klebsiella
pneumonia
|
Augmentin
and others
|
Penicillin group
|
Trachea aspiration
|
9/8
|
No Growth
|
K. Diagnoses/Provisional Dx/Acute/Chronic
Medical Problems:
1) Organophosphate
poisoning
2) Severe
Metabolic Acidosis
3) Aspiration
Pneumonia?
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