Case of the Month 12 – Presentation

You’re in the ED when an ESI 2 rolls up – an ill-appearing 75 year-old man who was brought in by EMS for nausea and vomiting x 3 days. The patient’s heart rate is 108, blood pressure is 136/82, and he is breathing 20 per minute. The triage nurse brings the patient to the critical care area where they are busy dealing with 3 gunshot wounds, 2 stabbings, and a room full of police officers. The resident quickly evaluates the patient and notices the patient looks dehydrated. They start a peripheral line, send some labs, and hang a liter of fluid. The patient is eventually sent to you in the main ED.

 

You go see the patient and here is what you discover:

 

75 year-old man with HTN, DM type II, dyslipidemia presents with 3 days of nausea and vomiting that began after he ran out of his insulin. He called his PMD who sent his prescriptions via E-prescribe but wasn’t able to pick them up because he couldn’t get out of bed. He has had no fevers, chills, URI symptoms, rashes or skin changes. His chest is burning but he attributes that to vomiting. He’s been taking Maalox® at home to make himself feel better. He has had no recent travel or sick contacts.

 

PSH: Hernia repair at age 4

Medications: Insulin detemir 30U qHS, sitagliptin 50 BID, metformin 1000 BID, amlodipine 10mg qD, atorvastatin 80 qD, lisinopril 40mg qD

Allergies: Penicillin – rash

Social: No drugs, alcohol or tobacco. Lives with son who has been on vacation the last 2 weeks.

 

PE:

VS: HR 110, RR: 20, BP: 148/100

GEN: Thin male

HEENT: Normal sclera and conjunctiva. PERRL, EOMI; dry mucous membranes; no lymphadenopathy

PULM: CTA BL

CV: Tachycardia, 2/6 systolic murmur

Abd: +BS, soft, minimal epigastric tenderness, non-distended, no rebound or guarding.

Ext: No cyanosis, clubbing, or edema.

The liter of normal saline is finishing when the lab results come back:

 

Venous Shock:  pH 7.274, PaCO2 44.2, Pa02 42.5, Na 130, Cl 80, HCO3 18 BE -5.8, Lactate 3.3

CBC: WBC 12; Hb 15; Platelets 350

Chem:  Na 119 K 3.8 Cl 80 HCO3 18; BUN 38 creatinine 1.5 Glucose 230 GFR 48

Serum ketone: negative

 

EKG: Sinus tachycardia, no ST-T abnormality

CXR: No consolidation

 

 

You give the patient additional IV fluids and admit to medicine for “dehydration”, but the patient still looks terrible.

 

  1. What is your differential?
  2. How do you use the ABG to put the story together?
  3. Is the lactate of 3.3 very concerning? What about in the setting of a base excess of -5.8? Why or why not?

 

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Steven Greenstein

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2 comments for “Case of the Month 12 – Presentation

  1. Ndana
    August 5, 2016 at 9:40 pm

    DKA high on my differential evwn though the glucose not quite as high as usual. Gastropareis/gastritis/boer haves. Pt has AG 20, with metabolic acidosis on the ABG. Lactate of 3.3 in this case is intermediate but with nausea and vomiting as as potential source of infection I would take this seriously and be more aggressive with this patient because he could get sicker easily.The base excess also supports my initial suspicion of met acidosis so still concerned.

  2. Dominik
    August 6, 2016 at 7:54 am

    Check for bowel obstruction.

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