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:

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 History 85, dementia

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/ WBC /uL11800 Hb g/dL15.3 Hct %46.1 MCV fL87.5 PLT 1000/uL 179 Seg91.4% Lym5.9% Mono2.7% Baso0.0% Eosin0.0% 生化 12/ ALT103 Bil (T)1.0 Cr1.4 Na137 K3.7

LAB 12/ / / PH P CO PO HCO SAO231.5%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

12/30 23:10, HR:151, BP 68/44mmHg, CVP level: 4cmH2O 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 12/30 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 stat SBP:70~8o mmHg 12/31 00:30 Irritable, midazolam 2.5mg IV stat SBP:70~8o mmHg Fluid challenge with N/S 1000 ml Dopamine 50ml/hr,(20mcg/kg/min) check hemogram, biochemistry and ABG Fluid challenge with N/S 1000 ml Levophed 40(20mcg/min)=> 50ml/hr(26mcg/min)

LAB 12/ / / PH P CO PO HCO SAO2 31.5% 95.8% 76.5% Vein gas 血液 12/ WBC /uL49600 Hb g/dL15.4 PLT 1000/uL 166 Atypical- Lympho 0.3% Meta- Myelocyte 1.0% Seg73% Band12.7% Lym10% Mono2.7% Baso0.3% Eosin0.0% 生化 12/ BUN15.9 Cr3.68 ALT98 Ca7.4 P3.5 Na145 K2.8 Cl115 Tn I Lactate99.9 ABG 12/ PH7.150 P CO234 PO HCO311.6 SAO299.2% FiO280% AaDO2309

12/30 23:10, HR:151, BP 68/44mmHg, CVP level: 4cmH2O 12/30 23:10, HR:151, BP 68/44mmHg, CVP level: 4cmH2O Fluid challenge with N/S 1000 ml Levophed 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 12/30 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 stat SBP:70~8o mmHg 12/31 00:30 Irritable, midazolam 2.5mg IV stat SBP:70~8o mmHg Fluid challenge with N/S 1000 ml Dopamine 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. 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