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1. Case 1. A 22-year-old woman with a history of depression presents to the ED 4
hours after ingesting 100 tablets of aspirin (325 mg) in a suicide attempt.
She denies any other ingestions.
Her vital signs are:
blood pressure, 110/60 mm Hg; NORMAL
heart rate, 120 bpm; TACYCARDIA
respiratory rate, 22 breaths/min; TACYPNEA
temperature, 99.1°F (37.3°C); FEBRILE
and pulse oximetry, 98% on room air. NORMAL
On physical examination,
the patient is mentating well. NORMAL
Lungs are clear to auscultation bilaterally, and she is tachycardic with a regular
rhythm. NO PUL EDEMA
Extremities are warm without edema. GOOD
Capillary refill is brisk. NO SHOCK
Laboratory results are:
sodium, 145 mEq/L HIGH END; potassium, 3.6 mEq/L NORMAL; chloride,106
mEq/L; NORMAL
carbon dioxide, 21 mEq/L; blood urea nitrogen (BUN), 8 mg/dL; creatinine, 0.9
mg/dL; and glucose, 122 mg/dL.
Serum drug screen reveals a salicylate level of 637 μg/mL (637mg/L)- severe
level and an acetaminophen level of 7.6 μg/mL.
Arterial blood gas testing on room air reveals:
pH, 7.41 NORMAL; Pco2, 32 mm Hg HIGH; Po2, 103 mm Hg HIGH; base excess, –
4 mEq/L; bicarbonate, 20 mEq/L; oxygen saturation, 97%; and lactic acid, 15.3
mg/dL.
Q1; What is the most appropriate initial treatment for this patient?
A. Administration of acetazolamide
B. Acetazolamide (worsen condition)
C. Haemodialysis
D. N-acetylcysteine (pcm)
(E) Sodium bicarbonate IV.
Forced hyperventilation is not indicated. (pt well)

2. HISTORY TAKING
Patient details:
Name; siti
Age; 22
Addresss; klang
Occupation; student
CC; ingestion of 100 tablet of aspirin
HOPI;
S
Ingestion of aspirin (take from mother medicine cabinet)
- Oral
- Dose 100 tab
- Duration 4 hr ago
- Intention for suicide, after some argument with boyfriend
- After that what happen, develop nausea sensation and vomiting
o Vomiting x 5 episode
o Sudden, after ingestion
o Food content, consist of yesterday food
o No blood
o No foul smelling
o No pain per abdomen
- Seizure (fitting episode)
o Involve whole body, after 10 min of vomiting
o Generalised
o For 5 min- 1 episode, not regaining consciousness (LOC)
o Associated with urinary incontinence, uprolling of eye
o No tongue bite, drolling of saliva
- No fever, no excess sweating/salivation, no blurred vision
- No hearing loss/ringing sound in ear, no sob, no feeling own heart beat
- No history unable to pass urine, no muscle spasm
- FAMILY HISTORY- RUBRIC!
o Supportive or not (family harmony)
o Fragile family
A
- No known allergy to drug and food
M
- Medication hx;
- on antidepressant (details unknown) since 5 year, no history of drug abuse
- no ivdu

3. P
- past medical and surgical history
- known case of depression since 5 year, dx at hospital X, on regular follow up
monthly, on medication (unknown details) claimed to be compliance to meds
- otherwise there is no history of admission due to depression and suicide
attempt
- no surgical history
L
- last meal/drink/urine/bowel at night before bed 10pm
- lmp; x/x/xxxx
E
- before going to bed, patient had a rift with boyfriend (better know the name-
for police report MLC) because some misunderstanding
- they didn’t settle on good term and she feel very stressed because of it, she
thought her life is going to be a doom without him
- she went back to kitchen and took aspirin from her mother medicine cabinet
- (no suicide note)
DR YAN NOTES.
- Admitted whether want to end her life or not
- Suicide refer psy
- Never discharge!
ph 7.41, normal 7.35-7.45
hco3 20, low 22-26
pco2 low 35-45
p02
hagma-met acidosis, low pco2 compensating by hyperventilation, partially
compensated
aspirin has mixed type acid base balance
1. Resp alkalosis
2. Hagma
3. Resp acidosis
Activated charcoal
1. 50gm
2. Adsorbed, increase surface area
3. Malaysia use tablet, need to crush or powder
Treatment
1. Fluid
2. Charcoal
3. Iv bicarb (urine alkalinazation)
4. Severe- hemodialysis (renal failure/acid base balance)

4. PRIMARY SURVEY
Airway - Patent and clear - no intervention
Breathing - RR 22bpm, tacypnea
- Spo2 98% RA (maintained)
- Not in respiratory distress
and pain
- no oxygen needed
(spo2 normal)
- lung ausculatation clear
bilaterally
Circulation - bp 110/60mmhg (not in
shock)
- pr 120 bpm (RRCV)
- periphery warm
- cft brisk
- iv cannula
- withdraw blood for ix
(bun, electrolyte, abg,
serum salicylates level
serially + other drug
serology, fbc, UFEME)
- *start fluid maintanence
(volume replacement if
shock)
- activated charcoal
- urine alkalinazation
(sodium bicarb)
Disability - mentating well
- conscious
- pupil?
- e4v5m6
- fit chart if still fiting?
Exposure - any abnormal smell ?
(suggestive other toxin)
- any hypo/hyperthermia
- cooling/warming
- ensure no available
toxin surround her
(aspirin)

5. --------------------------------------------------------------------------------------------------------
Case 2.
A 38-year-old farm worker presents to your ED with hypersalivation, urinary
incontinence, diarrhoea, and muscle weakness after being in a recently “sprayed
field”.
He has prominent wheezing and is producing copious amounts of clear sputum.
1. What is your diagnosis?
2. True or false.
A. Garlic like odor may assist in diagnosis.
B. Succinylcholine should be used when neuromuscular blockade is needed.
C. Tachycardia and pupil dilatation are end point for atropine therapy.
D. Atropine can reverse the muscle weakness.
E. Atropine is one of therapeutic agents for seizures.
3: Regarding organophosphate poisoning:
a. Salivation is sign of muscarinic effect
b. Occur through inhalation
c. Gastric lavage for organophosphate ingestion
d. History of exposure is needed to make a
diagnosis
e. Atropine is the drug of choice
4. Regarding carbamates:
a. Transiently inhibit the cholinesterase enzyme
b. Muscle weakness is the clinical feature for
carbamates poisoning
c. Activated charcoal is the treatment for carbamates
ingestion
d. Adrenaline is the drug of choice
e. Personal protective equipments to prevent from exposure

6. Case 3.
History: A 29-year-old comatose male arrives to your Emergency Department via
EMS, after having two seizures at home.
The paramedics state that en-route to the hospital he had a generalized tonic clonic
seizure that lasted 25 seconds.
According to family members, he has no prior history of seizures.
PMH: Suicide attempt (tried to cut wrists) four days ago.
Meds: Unknown
Physical Examination:
T: 101.1°F HR: 140 bpm RR: 22 breaths per minute BP: 180/99 mm Hg
General: Comatose.
HEENT: Pupils 6 mm bilaterally and sluggishly reactive to light.
There is no scleral edema or hemorrhage.
No gag reflex.
Pulmonary: Clear to auscultation bilaterally.
CV: Regular rhythm, tachycardic.
Abdomen: Hypoactive bowel sounds. Soft, nontender. Palpable bladder.
The cardiac monitor shows sinus tachycardia.
1. What immediate diagnostic and therapeutic measures should be indicated at the
bedside?
2. What is your differential diagnosis in this case?
3. What substance ingestions should be considered?
4. What therapeutic trial may help confirm the diagnosis?
5. How quickly should you expect a response to this treatment?

7. Case 4
A 35-year-old obese woman with a history of depression and previous self-harm
comes to the ED after an unwitnessed overdose. She claims to have taken 30
tablets of paracetamol four hours previously, along with a bottle of wine.
She has a history of chronic alcohol use and takes no regular medications.
Q1: What are the presenting features of PCM poisoning?
Q2: How would you manage this patient?
HISTORY TAKING