SITI FATEAH BINTI ALIAS 012011050972 CASE CLEARKING 1 1.

Identification Name : Abdul Gani bin Muhamad Nor Age : 46 years old Gander : Male R/N : SD 00446952

2. Chief complaint Brought in by ambulance today for aggressive behavior

3. History of presenting illness Unable to take history from patient, patient is opening eye to call for short while only, falls asleep again. 4. past medical/surgical history Follow up heroin addiction tested positive 2 months ago

5. Social history Drug addicted Not alcoholic drinker

6. Family history No history of hypertension, Diabetic Mellitus

7. Siblings Has 4 siblings He is number 4 in his family member

8. Drug and allergy history None 9. General examination Patient is drowsy but arousable for short while Hydration fair Not septic looking no vomit no fever BO normal Eye responds : Open spontaneously Verbal response : Confused Motor response : Obey Command 10. Physical examination Vital sign Temperature : 36.8 degrees Celsius Pulse rate : 148/min Respiration : 40/min Systolic blood pressure : 224 mmHg

Diastolic blood pressure : 141 mmHg Map : 158 mmHg SPO2 : 98%

Systemic exam Skin and lymph node Not anemic No lymph node enlargement

Mental status Normal

Cardiovascular system S1 S2 heard, dual rhythm no murmur

Respiratory system Lung clear. AE equal bilaterally

Alimentary system Soft and not distended No organomegaly

11. Differential diagnosis Aspiration pneumonia

12. Investigation Chest x-ray Urinalysis

 Full blood count (FBC) Red blood cell Haemoglobin Haematocrit Mean Cell Volume Mean Cell Haemoglobin Mean Cell Haemoglobin Concentration Red Cell Width Platelet Mean Platelet Volume White Blood Cells Percentage Of Neutrophil Percentage of Lymphocyte Absolute Lymphocyte 4.88 x10^12/L ( 3.80- 5.80) 12.9 g/dL ( 11.5- 16.5) 38.1 % ( 37.0- 47.0) 78.1 fl ( 76.0- 96.0) 26.4 pg abnormal ( 27.0- 32.0) 33.8 g/dL ( 30.0- 50.0) 16 % 386 x10^9/L (150-400) 7.25 fL 15.0 x10^9/L abnormal ( 4.0- 11.0) 83 % 12 % abnormal (40-75) abnormal (20-45)

1.79 x10^9/L ( 1.50- 4.00)

Blood acid base gases Lactate pH Total Carbon Dioxide Partial Oxygen Partial Carbon Dioxide Base Excess Bicarbonate Oxygen Saturation Calcium 1.20 mmol/L 7.249 Abnormal ( 7.350- 7.450) 24.9 mmHg 128.2 mmHg Abnormal ( 80.0- 100.0) 64.7 mmHg Abnormal ( 35.0- 45.0) 1.2 mmol/L 27.7 mmol/L 98.2 % 2.19 mmol/L ( 2.10- 2.55)

 Renal Profile (RP) Urea Sodium Potassium Chloride Creatinine 5.0 mmol/L ( 3.2- 9.2) 145 mmol/L (136-145) 3.6 mmol/L ( 3.5- 5.1) 109 mmol/L ABNORMAL (98-107) 147 umol/L ABNORMAL (62-115)

Liver function test Protein Albumin Globulin Albumin/Globulin Ratio Bilirubin Alanine Transaminase Alkaline Phosphatase 84 g/L ABNORMAL (64-83) 37 g/L (35-50) 47 g/L (34-50) 0.78 13.0 umol/L ( 3.4- 20.5) 47 U/L 89 U/L (40-150)

13. Diagnosis Amphetamine overdose Highly methadone overdose

14. Medication IV Augmentin 1.2 gr TDS ivd ds to 6 pints over 24hrs IV Naloxone infusion run at 14 mls/hr 15. Management Vital sign taken and recorded GCS taken Monitor BP