CASE PRESENTATIONCASE PRESENTATION

BY DR MUHAMMAD SAGHIRBY DR MUHAMMAD SAGHIR

BIODATABIODATA

Name: Ghulam RasulName: Ghulam RasulAge: 60yAge: 60y Address: Address:

Gujranwala Gujranwala Date of admission: 9/6/14Date of admission: 9/6/14

Mode of addmission: Mode of addmission: emergencyemergency

PRESENTING PRESENTING COMPLAINTSCOMPLAINTS

INTAKE OF 4 WHEAT PILLS 4hrs INTAKE OF 4 WHEAT PILLS 4hrs back back

ASOC 2HRSASOC 2HRS IRRITABILITY 3HRS IRRITABILITY 3HRS FEW EPISODES OF VOMITTINGFEW EPISODES OF VOMITTING PAIN AND BURNING IN PAIN AND BURNING IN

EPIGASTRIUMEPIGASTRIUM

H/O PRESENT DISEASEH/O PRESENT DISEASE Patient was alright few hours ago when he Patient was alright few hours ago when he

took 4 wheat pills after fight with his took 4 wheat pills after fight with his brother.he took 4 tabs from a local shop.Few brother.he took 4 tabs from a local shop.Few minutes after swallowing he started minutes after swallowing he started vomitting.he did not find any tablet in vomitting.he did not find any tablet in vomitus.when his family knew it they went to vomitus.when his family knew it they went to local hospital in gujrat where they did gastric local hospital in gujrat where they did gastric lavage and refered him to mayo hospital lavage and refered him to mayo hospital lahore.on his way he become irritable his lahore.on his way he become irritable his conscious level started to decrease. When he conscious level started to decrease. When he landed in our emergency ICU he was in ASOC landed in our emergency ICU he was in ASOC and too much irritable.there is no h/o fever, and too much irritable.there is no h/o fever, hypersalivation,excessive hypersalivation,excessive sweating,haemoptosis, haematuria, sweating,haemoptosis, haematuria, haemetemesis or malenahaemetemesis or malena

PAST HISTORRYPAST HISTORRY

He is non diabetic,non hypertensive He is non diabetic,non hypertensive and no h/o IHD.he is not a k/c of and no h/o IHD.he is not a k/c of hepatitis B&C, and any psychiatric hepatitis B&C, and any psychiatric disorder but he was hukka smoker disorder but he was hukka smoker

Drug history Drug history

There is no h/o drugs addiction, There is no h/o drugs addiction, alchole and any other medicationalchole and any other medication

ProfessionProfession

He was farmar by professionHe was farmar by profession

General physical General physical examinationexamination

BP 90/60 on support BP 90/60 on support Pulse 90/mint regular Pulse 90/mint regular R/R 20/mint R/R 20/mint Clubbing –ve Clubbing –ve Cyanosis –ve Cyanosis –ve Palmar erythema –ve Palmar erythema –ve No scar marks and no contracturesNo scar marks and no contractures Pallor +ve Pallor +ve Jaundice –veJaundice –ve No edema No edema Jvp not raised Jvp not raised Pupills were normal ,not dilated and not Pupills were normal ,not dilated and not

cnstrictedcnstricted

Systemic examinationSystemic examination

RESPIRATORY: there was no scar RESPIRATORY: there was no scar marks ,deformity,bulge or mass on marks ,deformity,bulge or mass on inspection breathing pattern was inspection breathing pattern was abdominothoracic.trachea was abdominothoracic.trachea was centrally placed.Air entry was equal centrally placed.Air entry was equal on both side with no crackles, on both side with no crackles, rhonchi but there was rhonchi but there was endinspiratory fine crepitationsendinspiratory fine crepitations

CVS CVS

There was no pathology seen on There was no pathology seen on inspection.Apex beat was in 5inspection.Apex beat was in 5thth ICS ICS there was no heave or thrill on there was no heave or thrill on palpation .Heart sounds were low palpation .Heart sounds were low intensity S1 or S2 was not loud, no intensity S1 or S2 was not loud, no murmur appriciated on auscultationmurmur appriciated on auscultation

JVP was not raisedJVP was not raised

GITGIT

There was no scar marks ,wound or any There was no scar marks ,wound or any mass on inspection.umblicus was mass on inspection.umblicus was centrlly palced and inverted.abdomen centrlly palced and inverted.abdomen was soft ,not distended it was mild was soft ,not distended it was mild tender on deep palpation.there was no tender on deep palpation.there was no mass and no visceromegly on mass and no visceromegly on palation,Bowl sounds were audible but palation,Bowl sounds were audible but stool not passed. There was no stool not passed. There was no ulceration,peteche and bleed in oral ulceration,peteche and bleed in oral cavitycavity

CNSCNS

He was drowsy and non responsive He was drowsy and non responsive but irritable with no focal deficet. but irritable with no focal deficet. His conscious level was 10/15 .there His conscious level was 10/15 .there was no focal deficet he was moving was no focal deficet he was moving all limbs freely. no cranial nerve all limbs freely. no cranial nerve lesion seen.pupills were normal and lesion seen.pupills were normal and reactivereactive

Fundoscopy Fundoscopy

On fundoscopic examination there On fundoscopic examination there was no papilledema, no was no papilledema, no haemorrhage and no anurysmhaemorrhage and no anurysm

Diagnosis Diagnosis

Wheat pill poisoning complicated by Wheat pill poisoning complicated by cardiogenic shockcardiogenic shock

investigationsinvestigations

CBC CBC Wbc 5.2Wbc 5.2 Hb 12.4Hb 12.4 Plt 82Plt 82 Hct 41Hct 41 S/E deranged S/E deranged Na 151Na 151 K 5K 5

LFTS derangedLFTS deranged ALT 252 ALT 252 AST 485 AST 485 Bi 2.5Bi 2.5 RFTS derangedRFTS deranged Urea 151 Urea 151 Cr 5.7Cr 5.7CKMB 34CKMB 34

ABGs uncompensated metabolic ABGs uncompensated metabolic acidosisacidosis

Ph 7.13 , 7.06 Ph 7.13 , 7.06 PCO2 24.2, 24.7PCO2 24.2, 24.7 Po2 80.3, 115 Po2 80.3, 115 Hco3 8, 7 Hco3 8, 7 Base excess -21, -23Base excess -21, -23 O2 sats 92, 98O2 sats 92, 98

ECGECG

In emergency it showed tachycardia, In emergency it showed tachycardia, Afib and VPCsAfib and VPCs

In ward it showed low voltage and In ward it showed low voltage and ST elevation in lead V1and V2 , no ST elevation in lead V1and V2 , no AFIB and no VPCs now AFIB and no VPCs now

CXR, USG AND ECHO planedCXR, USG AND ECHO planed

Case summaryCase summary

Patient Ghulam Rasul 60y old presented Patient Ghulam Rasul 60y old presented with injestion of 4 tabs of wheat pill. He with injestion of 4 tabs of wheat pill. He landed in ER after 4 hours in state of landed in ER after 4 hours in state of cardiogenic shock and cardiac cardiogenic shock and cardiac arrythimia. He was resuscitated in ER arrythimia. He was resuscitated in ER and was shifted to ward on Inotropic and was shifted to ward on Inotropic support. He remained in ASOC for 2 days support. He remained in ASOC for 2 days in ward and had developed multi organ in ward and had developed multi organ failure. Despite all the efforts, patient failure. Despite all the efforts, patient expired on 2expired on 2ndnd post admission day. post admission day.

Final diagnosis Final diagnosis

Wheat pill poisoning with multiorgan Wheat pill poisoning with multiorgan failure,(Cardiogenic shock,cardiac failure,(Cardiogenic shock,cardiac arrythmias,myocarditis,acute arrythmias,myocarditis,acute hepatitis and acute renal failure with hepatitis and acute renal failure with no ARDS)no ARDS)

TreatmentTreatment Inj solucortefInj solucortef Inj mgso4Inj mgso4 Inj risekInj risek Inj NAHCO3 Inj NAHCO3 Inj dopamine Inj dopamine Inj dobutrxInj dobutrx Tab vastral MRTab vastral MR Tab Enz 10 Tab Enz 10 INJ N/SINJ N/S