1. Case Conference Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea R2 임효석 / Prof. 장재영

2. Chief complaint Nausea O/S) 2006.11.31 17:00 pm Present illness 특이 병력 없던 26 세 남자 환자로 2 주 전 여자친구와 헤어진 후 우울 증세 보이던 중 2006 년 11 월 31 일 17 시 경 Acetaminophen (Tylenol 650mg x 50T, 32.5g) 을 이온음료에 섞어 복용함. 약물 복용 8 시간 후 (12 월 1 일 1:00 am) 개인병원 응급실에서 gastric lavage 시행 후 본원 응급실로 전원 (12 월 1 일 3:00 am) 되었으며 본원 응급실 L-tube insertion 시 bleeding 확인되어 응급 내시경 위하여 내과로 입원. 11876201 신 O 동 M/26 Admission : 06-12-1 3:00 am

3. Past medical history DM/HTN/Tb (-/-/-) 2006 년 2 월 acute hepatitis A 로 입원 치료 Family history : Family history : None Personal history Smoking : (-) Alcohol : (-)

4. Review of System General fatigue (+) febrile sense (-) chilling (-) myalgia (-) Skin diaphoresis (-) rash (-) itching (-) pigmentation (-) diaphoresis (-) pallor (-) pallor (-) Head & Neck headache(+) diplopia(-) tinnitus(-) Respiratory cough (-) sputum (-) dyspnea (-) tachypnea (-) Cardiac chest pain (-) palpitation (-) orthopnea (-)

5. Review of System Gastrointestinal swallowing (-) jaundice (-) abdominal pain (-) A/N/V/D/C (+/+/+/-/-) melena (-) hematochezia (-) Urinary dysuria (-) frequency (-) oliuria (-) Musculoskeletal pain (-) weakness (-) cramp (-) Neurologic syncope (-) seizure (-) dizziness (-)

6. Physical Examination Vital sign : 120/80 – 84 회 /min – 20 회 /min - 36°c SPO2 : 99% (RA) General alert mentality acutely ill looking appearance Skin no rash no pigmentation Head & Neck no neck vein engorgement cervical LN enlargement (-) Eye & ENT isocoric pupil PLR (++/++) whitish sclera pinkish conjunctiva PI (-) PTH (-/-)

7. Physical Examination Thorax clear breathing sound without crackle or wheezing regular heart beat withour murmur Abdomen soft & flat normoactive bowel sound tenderness (-) rebound tenderness (-) rigidity (-) muscle guarding (-) no palpable mass no abdominal bruit Back & Extremity CVA tenderness (-/-) pretibial pitting edema (-/-)

8. Initial lab finding (10 hours after drug ingestion) CBC/DC 9740/mm² -16.3 g/dl – 47.7 %- 104K (seg : 83.9%) aPTT 37.8/34 sec PT(INR) 18.7S54C13.3 (1.57 ) Chemistry TB/DB 2.05/0.58 mg/dL AST/ALT 120/137 U/L ALP/GGT 72/12 U/L protein/alb 7.5/4.7 g/dL LD/CK 580/79 U/L BUN/Cr 16/1.1 mg/dL Na/K/Cl 143/4.1/102 mmol/L Myoglobin 38.9 ng/mL Amylase 227 U/L ABGA 7.401 – 36.5 – 104.1 – 22.2 – 98.1 UA RBC 0-1/HPF WBC 0-1/HPF Bilirubin (-) Urobilinogen (-) Ketone 3+ SG 1.025 Protein (+-)

9. HR : 75 회 /min

11. Impression 1. Acetaminophen intoxication 2. GI tract mucosal injury due to L-tube, suspected

12. Diagnostic & Therapeutic plan 1. 혈중 Acetaminophen 수치 측정 2 회 이상 (4 ~ 6 시간 간격 ) 2. N-acetylcysteine 정맥 투여 (20 시간 protocol) * 환자의 몸무게 = 60 kg 3. Gastroscopy 150 mg/kg + 5DW 200mL for 15min 50 mg/kg + 5DW 500mL for 4hrs 100 mg/kg + 5DW 1L for 16 hrs 9000 mg + 5DW 200ml for 15min 3000 mg +5DW 500ml for 4hrs 6000 mg +5DW 1L for 16hrs

13. Serum Acetaminophen level 33.3 ug/mL High Risk 112.9 ug/mL

14. Gastroscopy (16 hours after drug ingestion)

15. Gastric erosion Hepatotoxicity PPI or H 2 blockerDetoxification

16. NAC 20 시간 protocol U/L 날짜 Ⅰ Ⅱ Ⅲ Ⅳ 11 시간후

17. Bilirubin mg/dL 날짜

18. Clinical course (Stage Ⅲ 72 to 96 hours) Symptoms RUQ pain (+) Nausea (+) Vomiting (-) Diarrhea (-) Jaundice (+) confusion (-) Physical examination Yellowish sclera Pinkish conjunctiva RUQ Td/RTd (+/-) Laboratory finding AST/ALT : 2050/6330 U/L Creatinine : 0.7~0.8 mg/dL Ammonia : 306 ug/dL

19. 4 days to 2 weeks Clinical course (Stage Ⅳ 4 days to 2 weeks) Symptoms RUQ pain (-) Nausea (-) Vomiting (-) Diarrhea (-) Jaundice (-) confusion (-) Physical examination Whitish sclera Pinkish conjunctiva RUQ Td/RTd (-/-) Laboratory finding AST/ALT : 66/1008 U/L Creatinine : 0.7~0.8 mg/dL Ammonia : 147 ug/dL

20. 2006.12.9 Vital sign : 120/80 – 80 회 /min – 20 회 /min – 36.6°c SPO2 : 99% (RA) Laboratory finding CBC/DC 6900 /mm 3 – 15.3 g/dL – 44.2% - 200K aPTT 39.6/34 PT(INR) 14.0S90C13.3 (1.07) TB/DB 0.69 / 0.30 mg/dL AST/ALT 66 / 1008 U/L Protein/alb 6.4 / 3.7 g/dL BUN/Cr 6 / 0.8 mg/dL Na/K/Cl 142 / 3.9 / 105 mmol/L  환자 연고지 관계로 인천에 있는 병원으로 전원