Monday, May 25, 2015

STUDI KASUS A



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?
at

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