2011.12.16指導醫師:許景瑋醫師 報告者: fellow 1 潘恆之. Name: 趙 o 林 Sex: male...
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Transcript of 2011.12.16指導醫師:許景瑋醫師 報告者: fellow 1 潘恆之. Name: 趙 o 林 Sex: male...
2011.12.162011.12.16指導醫師:許景瑋醫師指導醫師:許景瑋醫師報告者:報告者: fellow 1 fellow 1 潘恆之潘恆之
Name: 趙 o 林 Sex: male Age: 39 years old Chart number: 8767453 He visited our emergent room on 2011/11/04
Patient Profile
Acute onset of blurred vision lasts for one day.
Chief Complaint
This 39 y/o gentleman denied hypertension, diabetes mellitus or other systemic diseases.
He had experienced intermittent nausea, vomiting , and progressive anorexia since 11/01. Acute onset of blurred vision , dizziness, headache were noted since 11/04 morning. Besides, he suffered from intermittent bloody stool for 1 years.
No dyspnea, orthopnea, urine output decrease, abdominal pain, chest pain, fever, chillness or
cough.
He almost drinks every day. He often fogets to eat due to drunk. He drank 公賣局米酒 on 11/03 night.
Present Illness
He denied significant systemic diseases, such
as diabetes mellutis , hypertension, heart, kidney, or lung diseases.
Current medicine: nil
Past History
Allergy: no known allergy Alcohol: he drinks 米酒 at least 1 bottle per
day; betel-nut: denied; cigarette: 1 ppd/day since young age
Over-the-counter medication or chinese herb: denied
Personal History
Family History
No family history of diabetes mellutis, malignancy, heart, liver, kidney, or hereditary diseases.
Vital signs: T:36’C , P:116 bpm, R:17/min , BP:137/92
mmhg General apperance: chronic ill looking Consciousness: clear, GCS: E4V5M6 HEENT: conjunctive: not pale, sclera: anicteric pupil: 3mm/3mm , light reflex: +/+, EOM: full/full Chest: symmetric expansion , clear breathing sound Heart: regular heart beat without murmur Abdomen: soft and flat, normoactive bowel, no tenderness liver/spleen: impalpable, no palpable bladder Extremity: free movement, no pitting edema Digital rectal exam: yellowishy stool
Physical Examination
11/04 Laboratory Data
WBC 5800/ul
Hgb 13.5 g/dl
Hct 41.1 fl
MCV 89.2 pg/cell
RDW 15.1 %
PLT 189000/uL
PT 10.7 sec
INR 1.0
11/04 Laboratory data
ABG
PH 7.24
PCO2 16.3 mmHG
PO2 50.8 mmHG
HCO3 6.8 mm/L
SaO2 81.0 %
Osmo gap: Serum Osm – calculated Osm ( 2 [Na] + [BUN]/2.8 + [glucose]/18
+ [EtOH]/4.6) = 21.86 mOsm/kg
BUN 14.7 mg/dl
Creatinine 0.99 mg/dl
ALT 58 IU/L
NA 134 mEq/L
K 3.8 mEq/L
Sugar 124 mg/dL
Osm 302 mosm/KgH2O
Alcohol < 5 mg/dL
=> Anion gap: ?
11/04 Brain CT
Impression: subtle low attenuation in cerebellum and prominent cerebellar sulci. DDX: cerebral cortical atrophy or infarct, pleased clinical correlation.
Metabolic acidosis with high osmolar gap,
etiology? favor methanol intoxication related
Bloody stool, favor hemorrhoid related
Impression
Closely monitor vital signs, mental status and
consult ophthalmologist for thorough visual exam Complete metabolic acidosis survey, please check
anion gap, ketone, lactate, ethyl alcohol and urine AG
Suggest the patient take ethanol as antidote Arrange hemodialysis for increasing methanol
elimination Follow up methanol level, blood Osm, and ABG Give thiamine and watch out for alcohol withdrawal
Plans
11/05 Ocular Examination
OD OS
IOP soft soft
VA CF/50cm CF/50cm
Lid NP NP
CONJ NP NP
EOM full full
P Ortho Ortho
K clear clear
AC Deep/clear Deep/clear
IRIS NP NP
Pupil 3mm 3mm
L/R +/+ sluggish +/+
RAPD + -
Lens clear clear
F’d disc pinkish, hyperemia change, margin clear
disc pinkish, margin clear
Laboratory data
ABG 11/05 11/06
PH 7.319 7.445
PCO2 23.1 38.1 mmHG
PO2 47.5 90.1 mmHG
HCO3 11.6 25.5 mm/L
SBE -20.6 1.5 mm/L
SaO2 81.1 97.2 %
11/05 11/06
Cr 0.76 mg/d
AST 49 IU/L
ALT 38 IU/L
Osm 273 mosm/KgH2O
Methanol 45.6 < 0.1 mg/dL
Blood ketone
Negative
Lactate 12.3 mg/dL
HD HD
Other examination
11/07 Sigmoidoscopy :Impression: No active bleeder. Colon polyp, R-S colon Mixed hemorrhoid.
11/09 Brain MRI :
Impression:
Normal brain MR study.
11/09 Follow-up Ocular Examination
s/s : still blurred vision (ou) VA: ou CF/50cm RAPD: + (od) clear corea, AC and lens (ou) fundus: decreased hyperemia of the r’t
disc, but disc margin is sl. blurred
=> Discharge and OPD follow-up !!
Methanol are frequently found in high concentration
in automotive antifreeze and de-icing solutions, windshield wiper fluid, solvent cleaners, fuels, other industrial products, and adulterant in homemade distillates.
Most serious poisonings occur following ingestion; inhalation and dermal exposures rarely cause toxicity.
Lethal dose – 1 g/kg Toxicity dose – 0.25ml/kg of 100% methanol
(>8g)
Threshold of treatment – 20~25mg/dL
Summary of exposure
Methanol metabolism
1
33
6
Toxicity
( Liver )
( Liver )
Kidney : 3~5%Lung : 12%
Half life
8 hr
20 hr
Elimination
Adult: 8.5 mg/dl/hrChild: 0.88 mg/dl/hr
51hr
@
Clinical features
Early toxicity (acute intoxication) CNS : sedation, disinhibition, ataxia,
headache GI : abdominal pain, nausea, vomiting
Late toxicity (severe metabolic acidosis develops 6-12 hours after exposure )
HEENT : Ocular toxicity CV: tachycardia, arrythmia, bradycardia (fatal poisoning), cardiac arrest, severe hypotension Respiratroy: tachypnea, sudden respiratory failure Neurologic: coma, seizure, basal ganglia necrosis with parkinsonian features, polyneuropathy, optic atrophy GI: abdominal pain, anorexia, nausea, vomiting, necortizing pancreatitis (severe poisoning)
Clinical features
GU: acute renal failure, hamaturia Acid-base: metabolic acidosis (concurrent ethanol ingestion may delay acidosis > 1 hr ) Electrolyte: hypomagnesemia, hypokalemia, hypophophatemia Musculoskeletal: rhabdomyolysis (severe poisoning) Reproductive: birth defects of CNS (ingested together with other solvents)
Keypoints of PE: Vital sign, mental status, pupuils, thorough visual exam
Clinical features
Relative afferent
pupillary defect
@
Normal
Diagnostic testing
Finger sugar (rule out hypoglycemia, DKA, HHNK)
Arterial or venous blood gas , renal function,
electrolytes, serum osmolality, methanol, ethanol ,
ethylene glycol, isopropanol concentration, lactate,
acetaminophen and salicylate levels (to help
determine diagnosis) high anion gap? HCO3 <8 ? Osm gap
> 10 ? mild elevated lactate levels? ECG Pregnancy test in women of childbearing age
Keep airway, breathing, circulation : * Endotracheal intubation if mental status
change or respiratory failure hyperventilated with large minute ventilations to prevent profound
acidemia * IV crystalloid + vasopressors if hypotension
Treatment
Decontamination : * GI – not very useful ( methanol is rapidly absorbed and binds poorly to activated charcoal). Gastric aspiration by NG tube within 60 mins of ingestion maybe useful. * Eye – irrigate with water for > 15 mins * Dermal – remove contaminated clothing and wash exposed area with soap and
water
Treatment
Medication : a. If PH < 7.3, give Sodium bicarbonate 1-2meq/kg bolus + 132 meq in 1L D5W run 150-250cc/hr b. Antidote – ADH inhibition (give as soon as possible) * Fomepizole – 15mg/kg iv loading + 10mg/kg q12h x 4 doses Followed by 15mg/kg q12h if necessary * Ethanol – 8ml/kg of a 10% ethanol solution ivf loading + 1ml/kg/hr of 10% ethanol solution. Titrate serum EtOH to 100 mg/dL
Treatment
or
Hemodialysis -- rapidly remove both methanol and its toxic
acid metabolites (methanol half life 8 hrs 2.5 hrs) * Indication : a. Known methanol intoxication -- High anion gap metabolic acidosis -- End organ damage (visual changes) b. Suspected methanol intoxication -- Unexplained high anion gap metabolic acidosis + high plasma osmolar gap ( PH < 7.3 if strongly suspected, PH < 7.1 if weakly susected)
Treatment
Cofactor therapy – combine with ADH
inhibition Folinic acid (leucovorin) 50mg iv q4-6hor Folic acid 50mg IV q4-6h increases clearance of formate
Admission criteria: acidosis, visual symptoms, or methanol >
25mg/dL
Treatment