1. Presented by F1 林立原 Instructed by Dr. 許景瑋 2011/11/11

2. General Data  Age: 45-year-old  Gender: male  Ethnic: Taiwanese  Marital status: single  Occupation: worker

3. Chief Complaint  Burning clothes in room with drowsy conscious

4. Present Illness  This 44-year-old male has unremarkable medical history except aloholism and alcoholic liver disease. He was sent to the ED because of burning clothes in room with drowsy conscious, which was noticed by his elder brother.  At ED, brain CT showed no intracranial hemorrhage. CO-Hb level was 23%, along with profound shock, leukocytosis and bandemia.

5. Past History  No hypertension or diabetes mellitus  No operation history of major organs

6. Personal History  No known allergy to food or drugs  Smoking: denied by his brother  Alcohol consumption: heavy drinker  Betel nuts chewing: denied by his brother

7. Physical Examination  T 36 ℃ P: 125/min, R: 24/min, BP: mmHg  Height: 160cm, weight: 50kg, BMI:19.5  Consciousness: E4V4M6  HEENT: pink conjunctiva, no thyroid goiter  Chest: rapid and labored respiration, bilateral clear breathing sounds.  Heart: regular heart beats, no murmurs.  Abdomen: soft, flat, normal bowel sounds  Extremity: freely movable, no pitting edema.  Skin: ecchymoses over lips, knees and legs

8. Laboratory Findings Hemogramunit10/07 WBC/uL23200 RBCmillion/uL2.55 Hemoglobing/dL9.5 Hematocrit%26.3 MCVfL103.1 MCHpg/cell37.3 MCHCg/dL36.1 RDW%12.7 Platelets/uL76k Segment%55.0 Lymphocyte%7.0 Monocyte%7.0 Band%28.5 10/07 PTsec18.9 INR1.8 aPTTsec42.0 D-dimerNg/ml4552

9. Laboratory Findings BiochemistryUnit10/07 BUNmg/dL37.2 Crmg/dL2.87 NaMeq/L135 KMeq/L2.7 ASTU/L167 CRPmg/L176 Troponin Ing/mL0.170 AmmoniaUg/dL65 MyoglobinNg/mL338

10. Laboratory Findings BiochemistryUnit10/07 T- HBg/dL1010.5 O2 HB%73.698.1 CO HB%23.00.5 MET HB%1.10.1 O2 SAT%97.098.7 Alcohol<5 Benzod475 Amphetaminabsent Unit10/07 pH7.32 CO2mmHg26.4 O2mmHg303 HCO3Mm/L13.4 Sat%99.7

11. Laboratory Findings Urinalysis10/07 ColorDark Yellow TurbidityCloudy Sp. Gravity1.015 pH5.5 Leukocyte2+ NitriteNegative Protein1+(30) GlucoseNegative KetoneNegative Urobilinogen2.0 BilirubinNegative Blood2+ RBC20 WBC106 Epi.8

12. CXR

13. Hospitalization course Cr: 2.87 (10/7) Cr: 0.46 (10/9) 10/21 Fasciotomy Ceftriaxone 10/07~10/12 Ceftazidime 10/12~11/03 Musculoskeletal CT MBD 11/04

14. Impressions  Carbon monoxide intoxication  Septic shock, focus: left hand cellulitis and urinary tract infection; urine and wound culture: Pseudo. aeruginosa  Acute kidney injury, RIFLE-F, due to rhabdomyolysis  Macrocytic anemia, favor alcoholism related  Acute hepatitis, consider shock liver

15. Discussion

16. The end