2. General data T. E. 39 year old Male Catholic From Mandaluyong City
Admitted last June 23, 2014

3. Chief Complaint
Burn

4. History of Present Illness
Few hours PTA,
While fixing a defective LPG, patient accidentally lit up a candle causing explosion

5. Past Medical History (-) DM (-) Hypertension (-) Cardiac diseases
(-) Pulmonary tuberculosis
(-) Asthma
(-) Cancer
No allergies to food and drugs

6. Family Medical History
(-) Cancer
(-) DM
(-) Hypertension
(-) Pulmonary tuberculosis

7. Personal and Social History
Smoker
Occasional alcoholic drinker
No illicit drug use

8. Physical Examination
General: awake, conscious, coherent, in cardiorespiratory distress
HEENT: anicteric sclera, pink palpebral conjunctiva, no cervical lymphadenopathy
Thorax and lungs
Symmetrical chest expansion, no retraction, no chest lag, clear breath sounds

9. Cardiovascular
adynamic precordium, regular rate and rhythm, no murmur
Abdomen
Flat, normoactive bowel sounds, soft, non tender
Extremities
(+) flame burn

10. 06/23/14
06/26/14
RBC count
6.5
4.6
Hemoglobin
1909
132
Hematocrit
0.61
0.40
Platelet count
237
194
WBC count
27.5
Neutrophil
0.84
0.83
Lymphocytes
0.10
Eosinophil
0.01
Monocytes
0.06
0.05
6/23/14
6/26/14 Na
142
148 K
4.70
3.20 Cl
112
114
BUN
5.60
4.40
Crea
88.90
92.80
Total Protein 29 31
Albumin
9.93
6.43
Globulin
19.1
24.6
A/G Ration
0.5
0.3

11. Chest Xray (06/23/14)
Clear lungs
Magnified cardiac silhouette

12. PT, PTT
06/23/14
(5am)
(5pm)
06/26/14
Protime
15.1
20.6
15.7
% activity 77 46 72
INR
1.18
1.74
1.24
APTT
24.3
31.9
13.3

13. 1st Hospital Day Patient admitted Intubated Therapeutics given:
Paracetamol 600mg TIV
Flammacerium cream
Cefuroxime 750mg/ TIB q8
Omeprazole 40mg/tab
Mebo ointment

14. 2nd Hospital Day CVP inserted Monitor VS and recorded
Seen by SICU rotator
Started salbutamol nebulization

15. 3nd Hospital Day ABG done Discontinued salbutamol nebulization
Started heparin nebulization
Anesthesia referral – was given midazolam for agitation

16. 4th Hospital Day Medications were continued Repeat ABG done
Started KCl drip
Continued OF Feeding

17. 5th Hospital Day Asystole CPR started Epinephrine
DNR signed by relatives

18. Final Diagnosis
Cardiopulmonary Arrest secondary to Acute Respiratory Distress Syndrome secondary to Smoke Inhalational Injury
Flame Burn 70% TBSA superficial partial thickness to deep partial thickness