Patient Encounter Part 2

Physical examination and laboratory studies reveal the following additional information about CH.

VS: BP 148/87 mm Hg, pulse 115 bpm, RR 23/min, T 39.0°C (102.2°F), ht 180 cm (5'11"), wt 80 kg (176 lb)

CNS: Unresponsive, unarousable

CV: Sinus tachycardia; normal S1, S2; no murmurs, rubs, gallops

Pulmonary: Tachypneic; oxygen saturation 92% on room air; no rhonchi, wheezes, rales

Abdomen: Firm, nontender, nondistended; (+) bowel sounds; no hepatosplenomegaly Extremities: Rhythmic tonic-clonic movements of all extremities GU: Incontinent of urine and stool HEENT: Persistent upward gaze

Labs:

Sodium 130 mEq/L (130 mmol/L) WBC 12 x 103/mm3 (12 x 109/L) Phenytoin 2.1 mcg/mL (8.3 p,mol/L) Albumin 3.5 g/dL (35 g/L) Potassium 3.5 mEq/L (3.5 mmol/L) Hemoglobin 14 g/dL (140 g/L or 8.7 mmol/L) Chloride 100 mEq/L (100 mmol/L) Hematocrit 42% (0.42 volume fraction) Carbon dioxide 12 mEq/L (12 mmol/L) Platelets 235 x 103/mm3 (235 x 109/L) Blood urea nitrogen 10 mg/dL (3.6 mmol/L) Prothrombin time 12 seconds Serum creatinine 0.9 mg/dL (80 ^mol/L)

International Normalized Ratio 1.1

Glucose 189 mg/dL (10.5 mmol/L)

Activated partial thromboplastin time 28 seconds

What is your assessment of the cause of this patient's condition?

Identify your goals of therapy for this patient.

What therapies must be instituted next?

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