Detailed Treatment Process
16 min read
Male, 80 years old
Triage form Triage department: Neurology Emergency (Internal Medicine) Level I BP: 188/140 mmHg P: 181 beats/min SpO2: 64% Please keep this form safely for registration and payment Triage time: July 25, 09:13 Medical record July 25, 7:00 AM (Emergency) July 25 Physician seal
First report: Non-contrast head CT Department: Emergency Internal Medicine Clinical diagnosis: Coma Request from referring physician: Assist in diagnosis and treatment Examination site and name: Non-contrast head CT Radiological findings: Small punctate low-density shadows are visible in the bilateral basal ganglia and semioval centers, with ill-defined borders. The remainder of the brain parenchyma shows no obvious abnormalities. The ventricles are dilated, the sulci and fissures are widened, and the midline structures are in the midline. Radiological diagnosis: Lacunar infarcts in the bilateral basal ganglia and semioval centers; senile brain. Examination time: July 25, 11:55:18 Report writing time: July 25, 12:07:04 Report review time: July 25, 12:17:42 Second report: Non-contrast chest CT Department: Emergency Internal Medicine Clinical diagnosis: Coma Request from referring physician: Assist in diagnosis and treatment Examination site and name: Non-contrast chest CT Radiological findings: The chest is symmetric. Both lungs show normal radiolucency. Multiple patchy and nodular opacities with fibrous strands are seen in both lungs, with ill-defined borders. No obvious abnormal density shadows are seen in the remaining lung fields. The visualized bronchi are patent. The trachea and mediastinum are midline. The hilar structures are normal. Enlarged lymph nodes are seen in the mediastinum. There is partial wall calcification of the aorta and coronary arteries. The heart size and shape are normal. Both hemidiaphragms are smooth. The costophrenic angles are clear. There is bilateral pleural thickening. No pleural effusion. Incidental finding: Spotty dense shadows in the gallbladder. Radiological diagnosis: 1. Infectious lesions in both lungs; tuberculosis cannot be excluded—please correlate with clinical findings. 2. Bilateral pleural thickening and arteriosclerosis. 3. Incidental finding: Gallbladder stones. Examination time: July 25, 11:55:27 Report writing time: July 25 Report review time: July 25
Third report: Electrocardiogram Date: July 25, 18:04:04 P: 100 ms QT/QTc: 336/457 ms Atrial rate: 111 bpm QRS: 88 ms QRS axis: +71° Ventricular rate: 111 bpm P-R: 132 ms RV5/SV1: 1.99/0.62 mV Paper speed: 25 mm/s Sensitivity: 10 mm/mV MF: 60 Hz Diagnostic impression: Sinus tachycardia
Laboratory report (complete blood count) Department: Emergency Neurology Sampling: July 25, 18:07 Item \ Result \ Reference range 1 Whole blood C-reactive protein 57.30↑ (<5 mg/L) 2 Leukocyte morphology microscopy Examined 3 White blood cell count 20.02↑ (3.5-9.5 × 10⁹/L) 4 Lymphocyte count 0.43↓ (1.1-3.2 × 10⁹/L) 5 Monocyte count 0.73↑ (0.1-0.6 × 10⁹/L) 6 Neutrophil count 18.81↑ (1.8-6.3 × 10⁹/L) 7 Eosinophil count 0.02 (0.02-0.52 × 10⁹/L) 8 Basophil count 0.03 (0-0.06 × 10⁹/L) 9 Lymphocytes 2.1↓ (20-50%) 10 Monocytes 3.6 (3-10%) 11 Eosinophils 0.1↓ (0.4-8%) 12 Basophils 0.1 (0-1%) 13 Neutrophils 94.1↑ (40-75%) 14 Red blood cell count 4.31 (4.3-5.8 × 10¹²/L) 15 Hemoglobin 126↓ (130-175 g/L) 16 Hematocrit 38.50↓ (40-50%) 17 Mean corpuscular volume 89.3 (82-100 fL) 18 Mean corpuscular hemoglobin 29.2 (27-34 pg) 19 Mean corpuscular hemoglobin concentration 327 (316-354 g/L) 20 Red cell distribution width CV 13.5 (12.2-14.8%) 21 Red cell distribution width SD 44.6 (41.2-53.6 fL) 22 Platelet count 446↑ (125-350 × 10⁹/L) 23 Mean platelet volume 8.80↓ (9.4-12.6 fL) 24 Plateletcrit 0.39↑ (0.16-0.35%) 25 Platelet distribution width 8.60↓ (9.8-16.1 fL) 26 Large platelet cell ratio 14.9↓ (19.2-47%)
Laboratory report Age: 80 years Department: Emergency Neurology Specimen: Blood Sampling: July 25, 18:07 Diagnosis: Loss of consciousness Item \ Result \ Reference range 1. B-type natriuretic peptide (BNP) 173.07↑ (<100 pg/ml)
Laboratory report (blood gas analysis) Department: Emergency Internal Medicine Specimen: Blood Sampling: July 25, 18:22 Diagnosis: Loss of consciousness Item \ Result \ Reference range 1. pH 7.365 (7.35-7.45) 2. Hydrogen ion concentration 43.20 (35-45 nmol/L) 3. Partial pressure of carbon dioxide 48.80↑ (35-45 mmHg) 4. Partial pressure of oxygen 53.50↓ (80-100 mmHg) 5. Sodium ion 139.00 (135-148 mmol/L) 6. Potassium ion 3.00↓ (3.5-4.5 mmol/L) 7. Chloride ion 97.60↓ (98-107 mmol/L) 8. Ionized calcium 1.06↓ (1.12-1.32 mmol/L) 9. Lactate 0.84 (0.5-1.7 mmol/L) 10. Effective oxygen saturation 90.50↓ (95-99%) 11. Total hemoglobin concentration (tHb) 129.70 (126-174 g/L) 12. Actual bicarbonate concentration 27.30 (21-28 mmol/L) 13. Standard bicarbonate concentration 25.10↑ (21-25 mmol/L) 14. Base excess 1.30 (-3-3 mmol/L) 15. Extracellular fluid base deviation 1.90 (-3-3 nmol/L) 16. Plasma total carbon dioxide concentration 64.40↑ (24-32 vol%) 17. Whole blood total carbon dioxide concentration 24.60 (24-32 mmol/L) 18. Oxygen tension at 50% hemoglobin saturation 23.90↓ (25-29 mmHg) 19. Alveolar-arterial oxygen tension difference 39.20↑ (5-25 mmHg) 20. Anion gap 17.10↑ (10-14 mmol/L) 21. Hematocrit 42.20 (34-48%) 22. Total oxygen content 16.20 (16-23 vol%) 23. Oxyhemoglobin (O₂Hb) 89.10↓ (90-95%) 24. Carboxyhemoglobin (COHb) 1.00 (0.5-1.5%) 25. Methemoglobin (MetHb) 0.70 (<0.8%) 26. Deoxyhemoglobin (HHb) 9.30↑ (1.4-4.9%) 27. Standardized ionized calcium 1.04↓ (1.13-1.35 mmol/L) 28. Functional oxygen saturation 86.20↑ (%) 29. Respiratory index 73.00↑ (%) 30. BB 48.40 (45-55 mmol/L) Test time: July 25, 18:22 Report time: July 25, 18:27
Visit record Visit time: July 25, 09:26:43 Visit department: Emergency Internal Medicine Chief complaint: Convulsions with loss of consciousness for more than 1 hour History of present illness: One hour ago, the patient suddenly developed convulsions and coma without obvious precipitating factors. 120 was called. Temperature measured by 120 was 40°C. No vomiting. Page 3 of 73 Physical examination: Temperature 40°C, fingertip oxygen saturation 69%, blood pressure 188/110 mmHg, respiratory rate 20 breaths/min, comatose. Pupils equal and round, sluggish light reflex. Facial and limb twitching. Rapid breathing. No verbal response. Pale face and lips. Supple neck without resistance. Coarse breath sounds in both lungs, no rales. Heart rate 100 beats/min, regular rhythm, no murmurs. Soft abdomen, no masses. Liver and spleen not palpable below the costal margin. No abdominal tenderness, rebound, guarding, or rigidity. Murphy sign negative. McBurney point negative. Diagnosis: 1. Coma Management: Informed family of critical condition. Explained that the patient is critically ill and may experience respiratory or cardiac arrest and death at any time. Family chose to forgo invasive resuscitation such as endotracheal intubation and tracheostomy to reduce suffering. Investigations: Non-contrast head CT (64-slice) once; non-contrast chest CT (64-slice + 3D) once; non-contrast upper and middle abdominal CT (64-slice + 3D) once; non-contrast lower abdominal and pelvic CT (64-slice + 3D) once; computer-assisted multi-lead ECG once. Laboratory tests: Emergency infection panel 1 once; emergency coagulation panel 7 once; heart failure ST2 protein once; blood gas once; emergency liver function panel 9 once; emergency renal function panel 4 once; emergency electrolytes panel 6 once; emergency cardiac panel 6 (without AST) once; emergency B-type natriuretic peptide precursor (PRO-BNP) once; emergency pancreatitis markers (blood) once; emergency infection panel 3 once. Page 4 of 73
Page 5 Medical record summary: History noted Date: Nasal cannula oxygen for 4 hours, fingertip oxygen saturation monitoring for 4 hours, cardiac monitoring Adhesive film dressing (6*7 cm) 1 piece, closed intravenous catheter (18G/20G/22G/24G) 1, single-use arterial blood sampler (3 ml preset) 1, single-use infusion set (ultra-low density polyethylene, 0.7 mm winged needle with air inlet, standard type) 1 Prescription: Sodium chloride injection (0.9%) 0.9% * 250 ml/bottle 250 ml intravenous drip once daily, total: 1 bottle Lansoprazole injection 10 ml/vial 2 vials intravenous drip once daily, total: 2 vials Sodium chloride injection (0.9%) 0.9% * 250 ml/bottle 250 ml external use once daily, total: 1 bottle Sodium chloride injection (0.9%) 0.9% * 250 ml/bottle 250 ml external use once daily, total: 1 bottle Sodium chloride injection (0.9%) 0.9% * 250 ml/bottle 250 ml intravenous drip once daily, total: 1 bottle Glutathione injection 0.9 g/bottle 2.7 g intravenous drip once daily, total: 3 bottles Important notes and recommendations: Closely monitor vital signs Physician signature:
Page 6 Date: July 25 Consultation time: July 25 Consulting department: Neurology Consultation opinion and findings: History noted. Sudden high fever, loss of consciousness, and limb convulsions for more than 2 hours. Past history of arthritis. No prior epilepsy, hypertension, diabetes, heart disease, or cerebrovascular events. Internal medicine has given one intravenous dose of diazepam. Currently no obvious limb twitching. Neurology examination: Fingertip oxygen saturation 81% (on face mask oxygen), comatose, sluggish response to supraorbital pressure. Bilateral pupils 2 mm, light reflex present. No limb withdrawal to painful stimuli in all four limbs. Bilateral pathological reflexes not elicited. Supple neck without resistance. Kernig and Brudzinski signs could not be assessed. Emergency infection panel 1: C-reactive protein 95.09 mg/L, white blood cell count 19.9 × 10⁹/L, red blood cell count 4.14 × 10¹²/L, hemoglobin 124 g/L, platelet count 538 × 10⁹/L, hematocrit 38.80%, plateletcrit 0.55%, lymphocyte count 2.42 × 10⁹/L, neutrophils 84.3%, lymphocytes 12.1% Blood gas: pH 7.171, PCO₂ 5.86 kPa, PO₂ 6.6 kPa, O2Sat 71.5%, COHb 1.00%, FO₂HB 70.3%, FHHB 28.00%, MetHb 0.70%, K+ 4.50 mmol/L, Na+ 141 mmol/L, Cl 101 mmol/L, Ca2+ 1.14 mmol/L, Glu 7.70 mmol/L, Lac 16.00 mmol/L, Hb 13.1 g/dL, HCT 40.2%, BE-ECF -12.5 mmol/L, BE-B -12.1 mmol/L, HCO3 16.0 mmol/L, SBC 14.7 mmol/L, TCO2 15.4 mmol/L
Page 7 Date: July 25 Temperature 37.0, P 102 beats/min, O2CT 13.0 mL/dL, P 504.7 kPa, An. Gap 23.5 mmol/L ctBill 7.0 μmol/L Infection is confirmed, but the cause of coma remains unclear. Oxygen saturation is critically low, and the risk of sudden death during transport for further imaging is extremely high. We agree with current management by your department. Once vital signs stabilize, complete head CT to clarify further. Consider head MRI if necessary. Consulting physician: Visit time: July 25, 11:27:54 Visit department: Emergency Internal Medicine Emergency infection panel 1: C-reactive protein 95.09 mg/L, white blood cell count 19.9 × 10⁹/L, red blood cell count 4.14 × 10¹²/L, hemoglobin 124 g/L, platelet count 538 × 10⁹/L, hematocrit 38.80%, neutrophil count 16.79 × 10⁹/L, lymphocyte count 2.42 × 10⁹/L, monocyte count 0.62 × 10⁹/L, eosinophil count 0.04 × 10⁹/L, basophil count 0.06 × 10⁹/L Emergency coagulation panel 7: Prothrombin time 13.6 seconds
Page 8 Prothrombin activity 74.4%, INR 1.14, activated partial thromboplastin time 29.7 seconds, thrombin time 15.5 seconds, Fibrinogen 6.06 g/L, plasma antithrombin activity 81.9%, FDP 7.6 μg/ml, D-dimer (FEU) 1.52, Blood gas: pH 7.171, PCO2 5.86 kPa, PO2 6.6 kPa, O2Sat 71.5%, COHb 1.00%, FO2HB 70.3%, K+ 4.50 mmol/L, Na+ 141 mmol/L, Cl- 101 mmol/L, Ca2+ 1.14 mmol/L, Glu 7.70 mmol/L, Lac 16.00 mmol/L, BE-ECF -12.5 mmol/L, BE-B -12.1 mmol/L, Emergency cardiac panel 6 (without AST): Total protein 81.2 g/L, albumin 42.2 g/L, globulin 39.0 g/L, albumin/globulin ratio 1.1, total bilirubin 17.1 μmol/L, direct bilirubin 1.1 μmol/L, alkaline phosphatase 94 U/L, gamma-glutamyl transferase 31 U/L, alanine aminotransferase 28 U/L, aspartate aminotransferase 56 U/L, cholinesterase 3859 U/L, potassium 4.89 mmol/L, sodium 144.8 mmol/L, chloride 99.3 mmol/L, calcium 2.43 mmol/L, phosphorus 2.32 mmol/L, magnesium 1.01 mmol/L, carbon dioxide 19.0 mmol/L, creatinine 92 μmol/L, urea 2.31 mmol/L, uric acid 480 μmol/L, lactate dehydrogenase 296 U/L, creatine kinase 250 U/L, CK-MB activity 16.0 U/L, amylase 61 U/L, lipase 70 U/L, interleukin-6 99.33 pg/ml, procalcitonin (PCT) 0.15 ng/ml, high-sensitivity troponin I 4732 ng/L, myoglobin 98.0 ng/ml, CK-actin mass 2.28 ng/ml, B-type natriuretic peptide precursor 641 Page 8 of 73
Page 9 Diagnosis: 1. Coma; 2. Respiratory tract infection Management: -- Prescription: Sodium chloride injection 0.9% * 100 ml * 1 plastic bottle/bottle 2 bottles 100 ml intravenous drip twice daily Cefmetazole sodium for injection 0.5 g/vial 4 vials 1 g intravenous drip twice daily Sodium chloride injection 0.9% * 250 ml/bottle 1 bottle 250 ml intravenous drip once daily Piperacillin sodium and tazobactam sodium injection 5 ml: 1 g/vial 4 vials 4 g intravenous drip once daily Physician signature: Visit time: July 25, 15:37:56 Visit department: Emergency Internal Medicine Non-contrast head CT (64-slice): Lacunar infarcts in bilateral basal ganglia and semioval centers; senile brain Non-contrast chest CT (64-slice + 3D): Infectious lesions in both lungs, tuberculosis cannot be excluded—please correlate clinically. 2. Bilateral pleural thickening and arteriosclerosis. 3. Incidental: Gallbladder stones. Non-contrast upper and middle abdominal CT (64-slice + 3D): Gastric dilatation with fluid—please correlate clinically. Non-contrast lower abdominal and pelvic CT (64-slice + 3D): Prostatic hyperplasia with calcification. 2. Abundant gas and feces in rectum and colon—please correlate clinically. Page 9 of 73
Page 10 Patient remains unconscious. BP 145/95 mmHg, SpO2 70% (after face mask oxygen), HR 112 beats/min. Diagnosis: 1. Coma; 2. Respiratory tract infection Management: Suspected pulmonary tuberculosis at present. Recommend transfer to a specialized hospital for further treatment. Family understands and 120 has been called. Risks during transport explained. -- Physician signature: Page 10 of 73
Page 11 Chief complaint: Convulsions with coma for half a day. History of present illness: On July 25, the patient suddenly developed right-sided limb convulsions with loss of consciousness. He was taken to an outside hospital where head CT showed lacunar infarcts in the bilateral basal ganglia and semioval centers, and chest CT suggested pulmonary infection with tuberculosis not excluded. He was transferred to our emergency department that afternoon for further management. Past history: Denied Personal history: Denied Elderly patient assessment: Allergy history: No drug allergies. History of COVID-19 infection: None Family history: Denied Physical examination: Brought in on stretcher, lightly comatose. Coarse breath sounds in both lungs without obvious dry or wet rales. No edema in lower limbs. Page 11 of 73
Page 12 No supplemental oxygen: fingertip oxygen saturation 96% BP: 138/88 mmHg. Relevant auxiliary examinations: See history Preliminary diagnosis: 1. Light coma; 2. Cerebral infarction to be investigated; 3. Pulmonary shadows: pulmonary infection likely Management plan: Notes: The patient is currently in a light comatose state and critically ill, with life-threatening risk at any time. Recommend further evaluation in the neurology department of a general hospital. Discussed with family, who requested transfer to the neurology emergency department of an outside hospital for further care. Risks of transport explained. Family understands and signed. Physician signature: Page 12 of 73
Page 13 Date: July 25, 17:09:16 Visit department: Internal Medicine, Neurology BP: 142/99 mmHg SpO2: 91% Consciousness: Coma PR: 113 beats/min Chief complaint: Loss of consciousness for half a day. History of present illness: This morning at 8 o'clock, the patient was found still in bed (normally rises at 4-5 AM). Family noted right-sided limb twitching lasting about half an hour, loss of consciousness, and urinary incontinence. Sent by 120 to the emergency resuscitation room. Family could not accompany. Remained unconscious thereafter. Chest CT suggested possible pulmonary tuberculosis. Hospital recommended transfer to neurology. Accompanied by fever of unknown degree. Outside hospital head CT showed multiple lacunar infarcts and senile brain changes. Past history: ① Relevant past history: None Page 13 of 73
Page 14 (2) Relevant personal history: None (3) Drug allergy history: None (4) Family history: None Physical examination: Blood pressure 142/99 mmHg, pulse 113 beats/min, temperature 37.5°C, respiratory rate 21 breaths/min Comatose, pupils 2.5 mm, sluggish light reflex, bilateral pathological reflexes negative, Supple neck, 2 fingerbreadths below sternum, bilateral Kernig sign negative. Pain score: 0 Diagnosis: Loss of consciousness Previous auxiliary examinations: None Management: Auxiliary examinations: B-type natriuretic peptide (BNP); emergency biochemistry; coagulation; cardiac injury and heart failure markers; complete blood count Important notes and recommendations: Follow-up Supplemental blood gas Page 14 of 73
Page 16 Important notes and recommendations: Follow-up Emergency observation July 25, 20:05 Supplemental history: As above Emergency Internal Medicine Disposition: Family decided to forgo all invasive resuscitation measures and medications (including chest compressions, defibrillation, endotracheal intubation, tracheostomy, etc.) to reduce suffering. Page 16 of 73
Page 17 Visit department: Internal Medicine Observation Waiting time: 10 minutes Triage level: Level II Triage time: July 26, 02:32:34 Vital signs not obtained this triage! Patient refused measurement Please keep this receipt safely. Wishing you a speedy recovery! SpO2 94% BP 137/91 mmHg PR 113 beats/min Page 17 of 73
Date: July 25, 18:00 Emergency Internal Medicine: Contacted resuscitation room physician. Instructions: Vital signs stable. Complete investigations. Diagnosis: Loss of consciousness; pneumonia; hyponatremia; hypokalemia Current condition stable. Continue current treatment. Drug allergy history: None Prescription: Cefoperazone sodium and sulbactam sodium injection 1.5 g * 1 vial * 1 vial Usage: Skin test 1.5 g immediately Sterile water for injection 5 ml * 1 vial * 1 vial Usage: Skin test 5 ml immediately 0.9% sodium chloride injection 100 ml * 1 bag * 2 bags Usage: Intravenous drip 100 ml every 12 hours Cefoperazone sodium and sulbactam sodium injection 1.5 g * 1 vial * 4 vials Usage: Intravenous drip 3 g every 12 hours 0.9% sodium chloride injection 100 ml * 1 bag * 1 bag Usage: Intravenous drip 100 ml once daily Concentrated sodium chloride injection 10 ml * 1 vial * 3 vials Usage: Intravenous drip 30 ml once daily Fructose injection 250 ml * 1 vial * 2 vials Usage: Intravenous drip 250 ml twice daily 10% potassium chloride injection 10 ml * 1 vial * 2 vials Usage: Intravenous drip 7.5 ml twice daily Page 15 of 73