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
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