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!!