morning meeting

1. General Data
• 病歷號碼：21717159
• 年齡：48
• 性別：男
• 職業：無
• 種族：臺灣
• 婚姻：已婚

2. Chief Complaint
• General weakness for one week
– DDX
– AEIOU TIPs

3. Underlying disease
• Hx of pancreatitis
• T2DM

4. Underlying disease
• Pancreatitis at 2015/05 complicated with ARDS, necrotizing pancreatitis,
abdominal compartment syndrome
– s/p necrosectomy + drainage
• T2DM, diagnosed 2015/07, by OHA / Insulin, but poor compliance
– 2017 ~ 2019/08 : no medication record
– 2017/10/12 HbA1C=10.9%

5. Present illness
Abdominal pain
Poor appetite, nausea, thirsty sensation
Dyspnea, progressed for 2 weeks
Decreased urine amount
There was no fever, no chillness, no chest pain, no productive cough, nor limbs edema

6. Personal History
• Person Hx : Alcoholism
• Alcohol : 藥酒(Alc. 20~30%) 300cc/day for 10+ years
Smoking : 1PPD for 10+ years
Betelnut : 400$ for 10+ years

7. Physical Examination
• T:35.9 P:124 R:18 SBP:124 DBP:82 E:4 V:5 M:6
• Height : 164 cm BW: 51 kg BMI:19
• General appearance : ill, alochol smell
• Conscious : clear Pupil size : 3+/3+
• HEENT not anemic, not icteric
• throat- not injected
• Neck no jugular enlargement
• no lymphadenopathy
• Chest: BS clear
• Heart : RHB , no murmur
• Abdomen soft and flat
• no tenderness
• no rebound pain
• bowel sound : normoactive
• Mcburney point : negative
• Murphy sign : negative
• Extremities: free movable, no edema

8. lab
Temperature ℃ 37
pH 7.097
pCO2 mmHg 14.6
pO2 mmHg 126.7
HCO3 mmol/L 4.4
TCO2 mmol/L 4.8
ABE mmol/L -23.1
SBE mmol/L -25.3
SBC mmol/L 8.5
SAT % 98
檢驗項目 單位 1081113
血液組(CBC)
WBC 1000/uL 19.1
RBC million/uL 4.26
Hemoglobin g/dL 14
Hematocrit % 40.8
MCV fL 95.8
MCH pg/Cell 32.9
MCHC g/dL 34.3
RDW % 13.2
Platelets 1000/uL 327
Segment % 89.5
Lymphocyte % 4.8
Monocyte % 5
Eosinophil % 0.2
Basophil % 0.5
BUN (B) mg/dL 24.6
Creatinine(B) mg/dL 1.87
Na mEq/L 139
K mEq/L 5.1
Cl mEq/L 85
Lipase U/L 23
ALT/GPT U/L 19
Lactate(B) mg/dL 163.4
Osmolality(B) mosm/KgH2O 401
Methanol mg/dL <1.3
Alcohol mg/dL 298
Amphetamine(
U)
Absent
KETAMINE Negative
MDMA Negative

9. • Lactate acidosis
• Anion gap
• Delta-delta
• Osmo gap

10. Anion gap
• 139-4.4-85 = 49.6
• (49.6 – 10) / 19.6
Delta-delta

11. Osmo gap
• Calculated osmolality = 2 x [Na mmol/L] + [glucose mg/dL] / 18 + [BUN
mg/dL] / 2.8 + [Ethanol mg/dL / 3.7]
• 2 x 139 + 11.1 + 8.7 + 80.5 = 378.3
• 401 – 378 = 23

12. 鏡檢組(U)
Color Yellow
Turbidity Cloudy
SP.Gravity 1.013
pH 5
Leukocyte Negative
Nitrite mg/dL Negative
Protein mg/dL 2+ (100)
Glucose mg/dL Negative
Ketone mg/dL 1+ (15)
Urobilinogen EU/dL 1
Bilirubin mg/dL Negative
Blood 2+
RBC /uL 33
WBC /uL 0
Squamus Epi /uL 15
Hyaline cast /uL 1
Granular cast /uL 1
Bacteria Positive

13. Conclusion
• Metabolic acidosis with mixed with alkalosis

15. 檢驗項目 單位 1081114
血液組(CBC)
WBC 1000/uL 3.2
RBC million/uL 3.73
Hemoglobin g/dL 12
Hematocrit % 34.9
MCV fL 93.6
MCH pg/Cell 32.2
MCHC g/dL 34.4
RDW % 13.3
Platelets 1000/uL 147
Segment % 87.1
Lymphocyte % 8.5
Monocyte % 4.4
Eosinophil % 0
Basophil % 0

16. Impression
1. Alcoholic ketoacidosis
2. Lactate acidosis, metformin related?
3. T2DM with poor controlled

17. Acidosis

18. Hypokalemia
• Weakness, rhabdo
• Abdominal hypokinesia

19. hyperkalemia

20. treatment