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?
